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~ ~ ~eciar~ti~n ef DotniCile and Cltiz~nship 1~~ ;
~ TO TNE Sl'ATE AND COUNTY TAX ASSESSOR,
ST. IUCIE COUNTY, FLORIDA: ~ ' '
- This is my declaration of Domicile and Citizenship in the State of Flo~ide that I am filing this day 1~ aaordan~ca and
~ in conformity with Chapte~ 422, Sectic~n 2Z2.17, Florida Statutes. . -
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I wa: formerly a legal residont of
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(Ciry)
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j ~nd 1 ~eaided at _ _ . However I have changed my domfc~la :
i~ . (~treet and Number)
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to and am and have been a bona fide resident of ihe St~te of Florida sinte Y
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~ _ , 19~, and I resida at
~ , (St~eet and Numberj
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tl~ FORT PIERCE, SAINT LUCIE COUNTY, ~ORIDA ~
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and this statement is to be taken as my declarotion of citizenship, actual legal residanca and domicile in the Stat~ of Flo~ida.
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(Insert here any pertinent facts, such ~s sale of property or business, or relinquishmant of employmant ~
at farmer domidle, removal of family to new domicile, purchase of home, etc.) ~
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~ ~ ~ IN 29 P~ ~.3'~ , ; ~.,~1~• ~
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~ • ~ 1964 5, C\E?~~ ~ . • ~ ~ ' • , ~ ~ •
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I_ RTHER CHtTIFY that 1 will ~wm i with all other requirement= of a legal roaid~?t of thl: Stote. ~
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~ ~ I FURTHER CERTIFY that I have no intentian to return to my former domir~le, and i intend to rembin in FORT ~
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~ ~ ~PIERCE, SAiNT LUCIE ~OUNTY, ~LORIDA, pe~man~ntty..
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. `Swom to and :ubxribed befor~ ma this ~ day of , G~ . ~
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~:j ; K CIRCUIT URT Notary Public . ~
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gy ' Q.C. My Commisa(o~ expires ~
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i. Ro ~ ncscuhd in dupilcah and ori9inal fiHrd wit~ CtKic Cirarit Co~+~f, and dupilcat~ wilie Tsx As»~a
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