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~+e~claration af Domi~~le ~nd ~itizenshi~
, . . :~.~~D~S`?'
TO THE STATE AND COUNTY TAX ASSESSOR, ,
ST. WCIE COUNTY, FIORiDA:
This is my declarotion of Damicile and ~itizenship In the Stote of Fiorida that 1 am filinq tfiis day in aaordance and
in conformity with Chapter 222, 5ection 427.17, FIo~1da Statutes. .
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l I waa formeriy a IegA{ resident of
(City) (State)
.
i . ' . Hawevsr 1 hava cfisnged my domi~ile ~ ~
' •nd I ~asided at ~
r (Street atui Number) .
~ ~ ~ da of '
to and sm and have been a bona fide ~asident of the State of Florida :inca Y
. / ~D ~
, i Q~~, and I reaide at f~ (Streot and Number)
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, ~
fORT MERCB, SAINT LUCIE COUNTY, FtORlDA ~
r y~'
- a~ this statement is to be taken as my decta~ation of c~tizohship, actual legal roatdance and domicile in the State of Ho~ida. ~
!
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(Insert hera any pertinent fects, such as sale of property or businesa, or ~eilnquithment of omployment ~
~ at former damisile, removal of family to new domicile, purchase of home, etc.)
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PGI~R1~5•~'~~IDA - sr
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~ ~ 'f . lUC1E COUN~'I , f 1.0 . ,
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i HJRTHER ~£RTIFY that 1 will a~mply with al! other requirements of a lo~al roild~nt of thu StsM. - ;
i -
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r . I Ftfi2THER CERTIFY that I have no intention to return to my former domicile, end I intend to remain in ~ORT ;
PiER~~SAINT LUCIE COUNTY, FLORIDA, permanently. ~
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'y,~~~~='-'SWbr'n to and subsaibsd before me thi: ~ day af ~ - ~ i9
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f~~: CfRCU1T URT " . Notary Publk
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gy ' D.C. ~ My Commt~sbn expt~es .
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(To b~ ~x~cuhd in d~lical~ sud ~riyiw~l Rled w81b Ciirk Ciraiit Co~rt, ae~ d~sh w~i~ ta~c /1~ra '
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