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Decl~ratit~n ot DAmicele and Gi4izen$~eip ~
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TO THE STATE AND COUNTY TAX ASSESSOR,
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This is my declaration of Domicile and Citizenship in the State of Florida that I am filing this day in accordance and f
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in conformity with Chapter 222, Section 222.17, Florida Statutes. i
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I was formerly a legal resident of ~~ede ~'~aa8 ~
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(Ciiy} (State) }
47 R811eot~Tld Street However I have chan ed m domiCile ;
and I resided at - - _ - - ~ 9 Y
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(Street and Number) :
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to and am and have been a bona fide ~esident of the State of Florida since ~th day of i
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Novern~ier d~t 2Ul~ ~orth 19th Street :
- - - - , 1~--- , and f r~~ide at ;
(Street antl Number)
FORT PIERCE, SAINT LUCIE COUNTY, FLORlDA
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and this statement is to be taken as my declaration of citizenship, actual ~egal residence and domicile in She State of Florida.
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(Insert here any pertinent facts, such as sale of property or business, or relinquishment of employment t
at former domicile, removal of family to new domicile, purchase of home, etc.) f
Ne~ Domtcile
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` I FURTHER CERi~tY that I will comply with all other requirements of a legal resident of this State. E
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I FURTHER CERTIFY that I have no intention to return to my former domiSile, and I intend to remain in FORT ;
PIERCE, SAINT LUCIE COUNtY, FLORIDA, pzrmanently. s
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. . ~ . Pete Van Daele ;
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Srtilbtn~ to+'and~subscribed before me this _ 6th day of - J~~~ . 19 6b
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ROGER POItRAS - ~
CLERK CIRCUIY COURT Not~ry Public ~
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gy O.C. My Commission expires ~
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(To be executed in duplicate and original filed with Clerk Cirsuit Co~~rt, and duplicate with Tax I~ssessor.)
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BOOK ~35 :44~