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De~l~ra#ic~n c~f eomicile ~nd Cdt~z~nsl~ip t
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TO THE STATE AND COUNTY TAX ASSESSOR,
Sl. IUCIE COUNTY, FLORIDA:
fl~is is my declaration of Doinicile and Citizenship in the State of Florida that I am filing this day in accordance and
in conformity with Chapter 222, Section 222.17, Florida Statutes.
I was formerly a legal resident of ___.~~ritOt~R] N8W Jer~ey
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L~D ~ti V Vi1 ~.rl'f73 l~'i Li
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and I resided at _ . However I have changed my domiGile
(Street and Number)
to and am and have been a bona fide resident of 'he State of Florida since ~?nd. day of
November 65 158 Entra~a l1Ye. Po~ 5t, Lucia
- - 19---, and I reside at -
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
and ihis statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State ~f Florida.
(Insert here any pertinent facts, such as sate of property or business, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
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~ I FURTHER CERTIFY that I will comply viith all other res~uirements of a lega) resident of this ~tate.
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~ I FURTHER CERTIFY that I have no intention to return to my former domi~ile, and I intend to remain in FORT
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PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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_ M rs . M arie E. Sahmidt =
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~ Sworn to and subscribed before me this 5th _ day af - Ja~Y'! , 19 ~6 .
ROGER POITRAS
~ CLERK CIRCUIT COURT Notary Public
gy iLO~+~ _ D.~. My Commission expires
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~ (To be executed in duplicate and origina) filed with ~eRlc ~'t'~ ' Court, uplicate witfi Tax Assessor.)
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