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DedsratiJJ' ofJ~M~~ Citizenahip
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TO TilE STAT~ AND COUNTY TAX ASSESSOR,
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ST. Lt,rU; COUNTY, FLORIDA:
This is my <ledaration of Domicile and Citizenship In the State of )<'Iori<la that I am filing this day in accordance
allll ill c'ollformity with Chapter 222, Section <!22.17, Florida Statutes.
I was furmer!y a legal resident of
ROr. Kiln u
(City)
80~: .~3C~~' lC ..'-....~
State
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Old 1 own ;..:oau
\ Slreet allll Number)
However, I have changed my domicile
t" "",I am and have teen a b""R fide resilient crf the Slnte of Florida slllce
IS
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128 .: est, .' r i . 0.<
7isUl
01 v'.:.
(Steet and Number)
FOIlT I'IERCE, S.\INT LUCIE COUNTY, FLORIDA,
a..1 [hi~ ~talel1lcnt is 10 be taken as my declaration of citizenship', actual legal residence and domicile in the State of Florida.
(I n,ert here nny pertinent facts, such as sale of property or. business, or relinquishment of employment
lit former domicile, removal of family to new domicle, purchase of home, etc,)
~pplying for hcaestend
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I Fe RTH ER CERTH Y that I will register at my local address when the regiatration books reopen, and comply
-,,'ill. al! .!thl'l' requirements of a legal resident of this State,
I FURTHER CERTIFY that I have no intention to return 10 01)' fonner domidle, and I intend to remain in
H)HT PIERrE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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..,s:.ner J.
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bd IJ re 1I1 e this
I:O(;ER POITRAS
('I:ERK CIRCUIT COURT
Notary Public
By_..~.f~
D.C.
My Commission expires
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(fo he eXl'<'uled In duplicate and original filed with Clerk Circuit Court, and duplic.ate with Tax A& _or)
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