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T\J TIn: STATE AND COUNTY TAX ASSESSOR,
ST. I.lIIE <tll':\TY. FLOHWA:
This IS illY declarution of Domicile Ilnd Citizenship In th,' Slllt~ of Fhlrida thut 1 am filing this day In accordlUlce
a'ld in \'Ollf,lrntity with Chrptcr 222, Section 222.17, Florida Statutes.
.......
I w,"s formerly a legal resident of :3l\:(, ,;.a ~G
( Cit)')
~CLT.
Stale
;'~1 i 1 r('''II\-d at
Jenera1 ~e1ivery
(,,:rcet :11'" ~\lmber)
.i?th
day of
However, I have changed my domicile
t" ; III d:>l l\IIll L:>H' I>('('n (l h.'''1l fid" resillt:nt of the ~tate of Florilla since
}erJruary
63 10009 Inclcn ~iver Dr.
d)~ and I reside at
(Steet and Number)
rot:T PIERCE, S.\I~T LUCIE COUNTY, FLORIDA,
i\.,i 'I", ,t:i!.':;1l'nt is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Florida,
(IIH',I r,ere Rny pertinent facts, such as sal" of property or business, or relinquighment of employment
nt ;'"r'1H'r domicile, removal of f8mily to new Jomide, purchase of home, etc,)
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11-3285
FiLED f\HD RECG~OEO
It-: Offici8' RJCJUO_ ~OOK
\% 3 FEll 19 AN \0. i 2
ROGER PQnHA:',.rlE~;K
ST. LUCIE COU~I~~. '-LO~iO~ P .'
.tfJ ('c.j ~ It
I I-U:T1IEi: CERTI;'-Y that I wiIl register at m)' local adJre:;s when the registration books reo;>en, and comply
.." '" .d: ' '.11, r rt'quiremcnts uf a legal resident of this State,
I IT::TIIER CEI{TlFY that I have no intention to return to my fornler domicile, and I intend to remain in
!-"Oi:T ili-:I:<-l':, S,\I:-JT LUlIE COU~TY, FLORIDA, permanently,
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(Name)
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;!. Le. Dr SE :S~l2i\ET'r
(A:ldress)
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. h' 19th F~J~{L';,.-N
';'.',.. '>"1 "".~l,d ,'\lh,~'r:be,l Ul (,'re me t :~ ~_ dllY of ____.
, 19 6~3
i{O(;I-:l: POITRAS
'-I '":1:1-; ClRC{TIT COURT
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By _ /L -L..<,'_~1 . --..J~/\- ~ -:.,.. (d &
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Notary Public
D,C.
~ly COml11isSlOn expires
\'1"-, ill' nt'r,.L'd In duplic&te and oril:'inal file~ ",Hh Clerk (:Ircuit Courl, IhlJ duplitdte "ith Tax A~o:'~
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