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58 fA6E240
Decl",~ Dbtiik:ile ~d Citizenahip
--- --.--....
TO TilE STATE AND COUNTY TAX ASSESSOR,
...
:-;'1', LlTIE COV~TY, FLORIDA:
Thi~ is my 'Ieclarstion of DonJici:e and Citlunshlp in the State of Florida OMt t am fil1nlr this day in accordance
IUld in l'lln(ormity with Chapter 222, Section 222 17, Florida Slatute$,
I w"s (ormcrly a legal resident of
Boulder Juncrtion,
(City)
Wisconsin
Slate
a" I I rl'~id"d at
B~ulder Junction
(Street lInd Number)
However, I have changed my domicile
t" "n,! "Ill and hnve been a b::>na fide re!ilJent of the StatE: of Florida since
31st
December
w _6~--, and I reside at
l~02 Seawav Dr~ve.
(Steet and Number)
FOHT PIERCE, SAINT LUCIE COUNTY, FLORIDA,
Hi:d thi" ,tstl'llicnt i~ to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Florida.
lln,ert here an!' pertinent facts, such as sale of property or business, or relinquishment of employment
at funner domicile, removal of family to new domicil', purchase of home, e'.:.)
Applying for Homestead Exemption
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flL1Jl J\t~O RECORDEO
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I~~~ liAR -5 An 10: 0 I
ROGER POITHAS, CE;.,K /)
S1. LUCIE COUln~, fLORID^~~j/.
I n:HTIlER CERTIFY that I wiil register at my local address when the regi!;tration hooks reopen; and comply
wit;, .:li , thl'r requirements of a legal resident of this State.
I FUhTllER CERTIFY that I have no intention to return to my former domicile, and I intend to remain in
FOI:1' PIEHeE, SAINT LUCIE COUNTY, FLORIDA, permanently.
~
a.. /)~
{Name)
." :j '.J.~.": I
J) \ .....':... ,'-',:,10''':_ ~t
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1502 Seawoy Drive. Ftl Pierce. Florid~a
(Address)
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~"Wr.l'l\'~o:"allcl sub,cribed bd;)re me this
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" ;. 'HOGF:R POITRAS
('LERK CIRCUIT COURT
d....y ot
March
63
,., Hi
5th
"
.,
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n, __ t J.~ -~~ ClX\1l \~
Notary Public
D.C.
My CommlMlon e~irea
lTo he clll'cuted In duplicate and ollginal flied with Clnk Circuit OxIrt, &rid d;lplluu with Tu A8MM0r)
day of