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DeClaration ot DorniCile and Citizens~~ip
70 THE STATE AND COUNTY TAX ASSESSOR,
Sl . tUCIE COUNTY, FLORIOA: 2s1 r 9~
This is my dcclaralion of Domicilcs and Citizenship in the St~te of Florida that I am fiting this day in atto~da~ce anc!
in conformity with Chapter 222, Section 222.17, Flotida Statutes. .
. ~ ~ ~
formerl a 1 al ~esident of
1 was y eg
(Ci ) (State)
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and 1 resided at _~~1 a However I have changed my domitile
~ - (St~eet and Number) ~ . .
to and am and have been a bona fide resident of the State of Florida since ~U day of
~
' , 19~ and 1 reside ~at ' ~ ~
~ reet and Number)
FORT PIERCE, SAINT WCIE COUNTY, FLORIDA
and this statement is to be taken as my declaratio~ of citizenship, actual legal residence and domicile in the State of Florida.
(Insert here any pertinent facts,. such as sale of property oc business, or relinquishme~t of employment ~
at former domicile, removal of family to new domicile, purchase of home, etc.)
!/Applying~ for Homestead ~ , -
- Entering children in school :
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St ~~i~ C
~~R~C
4CW1~
Ca1RT L
. RECORO VfRtFlED ~
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' ' s A~I 73
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F - 261'799
1 FURTHER CERTIFY that { will comply with all other requirements of a legal resident of this State.
I FURTHER CERTIFY that 1 have no intention to return to my former domi~ile, and I intend to remain in FORT
( NtC M~It q~ ~
PIERCE, SAINT LUCIE. COUNTY, FLORIDA, permanently. ~
'
~/t ~ ed`, ~YI ~ Q.~v
~ . ~ ~ (Name)
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~ ':~r~~S~ro ~ s"ubscribed before me this day of , 19~
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• ~fr~., O~.~PbITRAS
~ ,~L~ttK CIRCUIT COURT No1ary Public
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e>y D.C. My Commission cxpires
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~ ~ do~217 ~E~?00
~ (To be oxeculed in duplicate and oriyinal (iled wi~h Gerk Circuit Court, and duplicato with 7ax Assossor.)
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