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DeClaration ot Domicile and Citizensl~ip
TO THE STATE AND COUNTY TAX ASSESSOR. 2b1~S
Sl. IUCIE COUNYY, FLORIDA:
This is my declaration of Domicilc and Citizcnship in the State of Florida that 1 am filing this day in acco~dante and
in conformity with Chapter 222, Section 222.17, Florida Statutes. .
1 was formerly a legal resident of , a- ~ d
(Ciy) . (State)
and 1 resided at _/7 L~ - ~ . However 1 have changed my domiCile
' (St~eet and Number) ~
to and am a~d have been a bona fide ~esident of the State of Florida since ~ s~ day of
_ , 19.Ls1, and I reside 'at . ~ ~ ~ ~ ~
~ ~~r~~~ ~~,~?~G (Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Flo~ida.
(Insert here any pertinent fads,. such as sale of property or business, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.) ~ '
Applying, for Homestead - . .
- Entering children in school :
. ,
_ . ~ ~ ~ra aECOaDE~ _ '
~YO~E COttNTlf ~L
' ~ ' ROCEa POITIt~S ~
~ CIERK CiRCU1T CO,URT
- RECORD YERIFIEd
' ~ ~C I~I 10 02 ~M'~3
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1 FURTHER CERTIFY that I will comply with all other requiremenfs of a lega) resident of this State.
I FURTHER CERTIFY that I have no intention to return to my former domicile, and I intend to remain in FORT
P(ERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. "~'L%S Sy~
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~ ~ ~ ~ (Name)
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OFj~••~~,~- . (Address)
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~ ='',;~r•~0 "~.to~iar~suhnc~ribed before me this I day of 19L~]
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~ "~'c4fi~K~~G~GiRRLUIT COURT Notary Public
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~ dy D.C. My Commission expires _
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~ (To bo oxocuted in du licato and ori inal filecl with Clerk Crcuit C
~ ~ ~ BOOK~~~I PAGE~~~~o with Tax Asscssor.)
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