HomeMy WebLinkAbout1019 D~ci~rati~n ~f Domi~ile ~nd Citi~ensi~in
TO THE STATE AND COUNTY TAX A~SESSOR,
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' ' 1. E ~
Sl. IUCIE COUNTY, FLORIDA:
This is my declaration of Domicile and Citizenship i~ the State of Fforida that 1 am filing this day in accordance and
in conformify wiih Chapter 222, Sectiori 222.17, Florida Statutes.
I ~vas formerly a le~al resident of _ Middletoun Ohio
~l.iiy) (5iaiej
1333 Lamberton Strget However ( have chan ed m domiCile
and I resided at _ _ _ _ - - - - . g Y
(Street and Number)
to and am ar~d have been a bona fide resident of the State of Florida since 1~. _ day of
February 701 Wendell Rt~d .
_ - _ - _ _ , 19-- , and I reside a1 ~
- - - - . _
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
and this statement is to be taken as rny declaration of citizer :hip, actual lega! residence anci dom~ti~e in the State of Florida.
(Insert here any pertinent facts, such as sale of property or business, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
FILE N,p , ~
~f~i~tal ~e °~~`o
Establishing residence --~'~0~.
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'b6 J~tJ I 8 P;.~ : 4~
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- . ~ _ - _ . Si. LJ~;L ~'v~; ~:Ty K .
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I FURT~-IER CERTIFY that I will comply with all other requirements of a legal resident of this State. -
I FURTHER CERTIFY that I have no intention to return to my former domiC+~~, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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, . . .
~ ~ ~ / .
, . - - . (Name)
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; ~ Glarence & k~lhe~mine ~isb~r i
. . . - '
' (Address)
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Swom to and subscribed before me this 18-- day of _ Janua~r ~ i9 ~
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ROGER POITRAS - - - - - ~
~ LERK GI UIT COURT Notary Public t
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~ gy D.C. My Commission expires a
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~ (To be executed in duplicate and original filed with Clerk Circuit Court, and duplicate with Tax Assessor.) ~
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