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Declal'auon of Domicile a-ntl ~itizenslZiP 80~K ~4 PA6E ~c,l~
- -~
- SST, Lt1Cl~ CCUldtY. FLA.
TO THE STATE A17D COUNTY TAX ASSESSOR,
ST. LUCI;:, COUNTY, F'...OP.IDA:
Thia is my declaration of 1omicile and Citizenship Ln the State of Florida that I am filing this day in accordance
and in conformity with Chapte~`~222; Section 222.1'1, Florida Statutes.
Cleveland ~ 24 Ohio
I was formerly a legal realdent of--- - State
[City]
and I realded at - 16138 Lyndht~st Rd - However, i have changed my domicile
[Street and Number]
to and am and have been a bona fide resident of the State o'f Florida since is day of
September 19~g2 and I reside at Rt 2 Bx 2986 Lakewood Pk .
- - [Street and Nwnberl
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA, '
and this statement is to be taken as my declaration of citizenship, actual legal residence anal domici'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 Lo new domicile purchase of home, etc•1 _
Establishing residency
Entering roan Elleti 2dueller in the 10th grade
l.i_is.i~~
- f~,EO AND RECDR~OK
- tN.-~'+
- .:~ 1961 o~c - ~ aM io: a~
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~. -~~ RO-~E i~ CD N ~{ SFLDRID A,
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I FUR:'HER CERTIFY that I wW register at my local a3dress when the registration bco?s reopen, and comply
with all other requirements of a legal resident of this State.
I FURTHER CERTIFY that I have no intentian to return to my i~rmer domicile, and I intend to remain in
I~ ORT PIERCE, SAINT LUCIE COUNTY, FL,O1tIDA, permanently. n
G/ (/ ~ .-
,I~ty nape ger
Sworn to and subscribed before me
ROG POITRAS ` a
ACLI-:R1C C1R 1T COURT .;;~• : ~~*
[To be execateb in dapiicat4 and 'or4ginxl ta:e3 ,t
[Address)
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(3oart, aa~l doPUcate with Tax Assesaorj