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De~laration of ~or~icile and C!tl~cenship ~
1 ~ ~
TO THE STATE AND COUNTY TAX ASSESSOR,
Sl. LUCIE COUNTY, FLORIDA:
Tt~is is my declaration of Domicile and Citizenship in the State of Florida that I am filing this day in accordanee and
in conformity with Chapter 222, Section 222.17, Florida 5tatutes.
Bethel Park Perul.
I was formerly a legal resident of
(City) (State)
and I resided at __2816_ _Bri~htWOOd Rd _ . However 1 have changed my domiCile {
(Street and Number) 1
~
to and am and have been a bona fide resident of the State of Florida since ~~h____ day of ;
i
~~.a.; ~
.Tana»i-rr : 19_~5 and I reside at _Ar~lor. Ava_ : _ _ _
- (Street and Number)? ~
FC>RT PIERCE, SAINT LUCIE COUNTY, FLORIDA ~
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ano inis siaien~eni IS ip Oe iaRen dS tit~i L7Ctla~aliVlt U~ ~itiZcit~tti~, d~iilai ~cya~ ic~iuc~i~c iai~v uv~~~,~C~~ • ~
a
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(Insert here any pertinent facts, such as sate of property or 6usiness, or relinquishment of employment ~
at former domicile, removal of family to new domicile, purchase of home, etc.)
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Appl~sing #'o~ homestead ~
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2
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~ ,,c•~f~ 0 p,ND REC~R OpK
:,,~'cG~, - ~ILE ,C~ ~
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_ .f ; . _ , ~Zy 10: 36 ~
. ~66 SAT . ~
' CLERK 3
•~,.,,~~'`.,.<.r Rp~E~ ~~1E2~~UN~Y~ ~
~ • ST. 1--U ~
FLG`~~~A ~
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I FURTHER CERTIFY that I will comply with all other requirements of a lega) resident of this State. ~
. ~
I FURTH~R CERTIFY that I have no intention to return to my former domiSile, and I inter.d to remain in FO(tT ~
PIERCE~~SAU~i' LUQ~S.'QUNTY, FLORIDA, permanently. ~
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: ~ . _ ,..r _ ~ - -
. Saznuel M~N~'siipster
; . :
~ . • i: ' -
'
. ' - ~ (Address)
2t{ v
Sworn to and subscribed before me this }h day of _ Je~Tlau't`y , 19 .
ROGER FOtTRAS
RK CIRCUIT S,OURT Notary Fublic
~-c-~~ ~~G~
D.C_ My Commission expires
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(To be execuled in duplicate and original filed with Clerk Cirtuit Court, and duplicate with Tax Auessor.)
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