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De~taration ot ~ornicil~ and ~itiaenship ~
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TO THE STAIE AND COUNTY TAX ASSESSOR,
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Sl. LUCIE COUNTY, FLORIDA:
Ti~is is my declara!ion of Domicile and Citizenship in the State of Florida ttiat I am filing this day in accordante and
in conformity wiih Chapter 222, Section 222.17, Florida Statutes.
I was formerly a legal resident of _Mishawaka _ Ind ~ ana
- (City)_ _ _ _ . _ (State) g
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and t resided at __719 W. I~SiShal9ak~_Avea-__________. . However I have changed my domitile ~
(Street and Number) ~
to and am and have been a bona fide resi~ent of the State of Florida since _ 1St_. day of ~
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Sept ~q_b_5, and I reside at _ I.nd,__~Zive.r_
Dr Jensen f3c,Fla, ~
(Street and Number) f
g
F6RT PIERCE, SAINT lUCIE COUNTY, FLORIDA ~~'r ~
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and this statement is to be taken as my declaration of citizenshj~, actuai legal residence and domicile in fihe Sfiafie of Ftorid~.
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(Insert here any pertinent facts, such as sale of Rr~perty or business, or relinqui~hment of employmenT ~
at former domicile, removal of family to new ddmicile, purchase of home, etc.) ~
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1 FURTHER CERTIFY that I will comply 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 #
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PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. j
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. . _ ~ 1'YLt.'''`'"`^' 1~ ~ ~
. • . . . ~
\ (Name) ~
. • . ~ She den Engle }
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- . ~ va En ;le
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Swo"rri~.to~ end ~subscribed before me this t n day of - .T a n au r y ~ ~ q o U
ROGER POITRAS ~
RK CIRCUIT COURT Notary Public ~
gy D.C. My Commission expires
(To be executed in duplicate and ori~inal filed with Clerk Circuit Court, and duptiwte with Tax Assesfor.)
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