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1]e~l~rat~on o~ ~e~miGiie Antl ~i~iz~nshi~ ~
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TO THE STATE AND COUNTY TAX ASSESSOR,
Sl. LUCIE COUNTY, FLORIDA:
This is n~y declaration of Domicile and Citizenship in the State of Florida that 1 am filing this day in atcordente and ~
in conformity with Cliapter 222, Section 222.17, Florida Statutes. ~
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I was formerly ~ legal residei~t of Har1ari Keniucky ~
- - -
(City) (Sfdte) ~
lll~dS~iv However I have chan ed m domiCile
and I res~ded at - - - ~ 9 Y
(Street and Number)
to and am and have been a bona fide resident of the State of Florida since ._?_th day of ~
anaar 66 Dixon Dr~.ve ( 408 i
J- --y---------, 19---, and I reside at ~ ,
(Street and Number) ~
FORT PIERCE, SAINY LUCIf COUNTY, FLORID~1
and this statement is to be taken as my c~eclaration of citizenship, actual lega) residence and domicile in fhe State of Florida.
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(Insert here any pertinent facts, such as sale of property or business, or relinquishment of employment ~i
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at former domicile, removal of family to new d~micile, purchase of home, etc.) €
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~~F~L~~ AND R ' t i
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Entering c~~ildren in school - (~jc~~~ ~~'R30p 9
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r I FURTHER CERTIFY that I will compiy with all other requirements of a legal resident of this State. ~
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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 ~
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently_ '
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: ` . • . . / 1
• rs (Name) s
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_ „c _ George Caldwell
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- ; (Address) ~
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'~•:!li~~:~1?\::
~ , Sworn to and subscribed before me this 12 day of Janaury , 19~~?.
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$
ROGER POITRAS ~
C~RK CIRCUIT COURT Notary Public ~
By - d`~~ ~ - D.C. My Commission expires ~
(To be executed in duplicate and original filed with Clerk Circuit Court, and duplicate with Tax Assessor.)
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