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OeCiaration of Domicite and Citizens~~~p
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TO THE STATE AND COUNtY TAX ASSESSOR, ;
51. lUC1E COUNTY, F~oR~oA: 261`730
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This is my declaration of Domicilc and Citizenship in the State of Florida that ! am filing this day in actordance ar?il ~
in conformity with Chapte~ 222, Section 222.17, Florida Statutes. ~
! was forme?ly ~ legal resident of . ' ~ ~ ~
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(Gy) (State)
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and 1 resided at _~t~L/jL.l~ll L~ . Howeve~ I have changed my domitile - i
- (St~eet and Number) ,
to and am and have bee~ a bona fide resident of the State of Florida since ---3-~~~ •~G day of
~-~/'f ~
-----~?14-~~° , 19..~.~., and I reside ~at ' ~l
~ l,,,C~.l~!! ,,Lllj~~i' ~(f
~ (Street and Number~
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FORT PIERCE, SAINT lUC1E COUNTY, FLORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domiciie in fhe State of Florida.
(tnsert he~e any pertine~t facts, such as sale of property or business, or relinquishment of employment
at former domicife, removal of family to new domicile, purchase of home, etc.j ~
Applying, for Homestead ~ ~ .
- Entering children in schooi : ~
~f • . ~ ~/d - ~ ' ~ .
~L ~/t 7 - ~/c~l ~ , ~i~E COUN~TY~lIA, ~
_ CIERK~C1RCUlT CO!!Rt ~
- RECORD VERIf1f0.,~„~`
. - ' . Auc il 2 ve PM'~3
261'730
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! I FURTHER CERTIFY that i wi!! comply with a!! other requiremenfs of a lega) resident of this State.
~ 1 FURTHER CERTIFY that I have no intention to return to my forrr~er domiCile, and I intend to remain in FORT
i PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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` . ~ ~ (Name)
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C, ~ , ' ....C D!j"~ 7 ,7 `
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:~`~•:;~'"~lc+' (Address)
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S~ ~;~ap;~ s~b,scribed before me this day of r q ~
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; ~ t~QER~,'I`~tAS ~
' CLEttK"rCIRCUIT COURT " Notary Public
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EY ~ D.C. My Commission expires ~
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' ~ooK21? ~20'~4 '
~ (to be oxecuted in duplicate aiid ori~inal !iled wilh Clark Circuit Court, and duplicato with Tax Assessor.)
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