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Declar~tion of DarrtiCile ~r~d ~dtizen~hip
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TO THE STATE AND COUNTY TAX ASSESSOR, '
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Sl. IUCIE C.OUNTY, FLORIDA: -1 i:~_~~j,`~„~„`~, ~
Tl~is is my declaration ~f Domicile and Citizenship in ihe State of Florida that I am filing this day in accordance and ~
in canformity with Chapter 222, Section 222.17, Florida Statutes. ~
~i~tjUt3li ~1SCOii~iil
1 was formerly a tegaf resident of - _ - - -
(City) (State)
and I resided at ___.1714 Vh~eSt_._l~leguOn_Rd _ . However I have changed my domiGile
(Street and Numbe~)
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to and am and have been a bona fide resident of the State of Florida since ~1_S.t__ day of i
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July 65 Rt 2 Box 3494 Lakewood Pk
. - - - , 19--- , and I reside at
(Si: eet and Number)
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
and this stater:ient is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Florida.
(Insert here any pertinent facts, such as safe of properiy or business, or reiinquishmeni of emptoyment
at former domicile, removal of family to new dornicile, purchase of home, etc.)
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Arplyin~ for homestead
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. ~ .`I ROGEf~ ~~f ~~R„S. CLERK ~
~ - - - ~ ST. LUClE
s.•.a w'l } ~
' COUNTY
~ „ FLORIDA ~
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~ I FURTHER CERTIFY that I will comply v,~ith 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 ~
i PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanenily.
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- i`~:~. (Name)
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' ~ - 'r _ william P. Hegerty
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_ ~ - ` (Address)
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'f Swom to and subscribed before me ihis 7th day of Februa~t , 19~~2.
ROGER POfTRAS
RK CIRCUIT COURT - Notary Public
' By ~Ot"~'~ D.C. My Commission expires
• (To bs executed in duplicate and origina) fi(ed with Clerk Circuit Court, and duplicate with ?sx Assassor.)
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