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ST. LtiClE COU:-.lTY, FLORIDA:
~taratiOD of DoMicile and Citizenahip
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Tv TIlE STAT~ AND COUNTY TAX ASSESSOR,
This is lilY decl.uatlon of Uomicile and Cititenship tn the State of Floridl\ that I i:m filing this day in accordance
and in ("'Idorlllity with Chapler 222, Section 222.17, Florida Statute~.
I was fornll'rly a legal resident of
E:1st Islip, LCIlG Islnrd
(City)
l~ e... -{ ork
State
;1'1 I resided at
2:3 ..:eroke Lone
(S.reet llnd Number)
have cl:tanRed my domicile
However,
30
tn and nm and have been a b:lI1a fide resilIent of the Stale of Florida since
day of
.;pri1
62 115 Luce..:'o D:'ivc
, and I reside at -
19
i.~rt St. Lucie
FOUl' I'IEnCE, SAI:-.lT LUCIE COUNTY, FLORIDA.
(Steet and NumQer)
n".1 this ,talcmenl i~ to be ta:len as my declare.Hon of citizenship, actual legal re!lidence and d:lmiciJe in the State of Florida,
(Insert here any pertinent facts, such as sale of property or business, or re:inquishment of employment
:It fonner domicile, ::-emoyal (,f family to new domicle, purehase of home, etc,)
d ;.lyinS for lie. .estee:d
1'13762
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ROGER pO, ~:)'( ')\ri\~\O~ .1/
SI, LUCIE. CU\l..". t t1.r~'
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I Ft:P.TIIF,R CERTIFY that I will register at my local address when the registration books reopen, and comply
wi:h all dh('!' requirements of a legal resident of this Sta.te.
I FURTHER CERTIFY that I h1lVe no intention to return to my former domicile, and I intend to remain in
FOltT i'IE){(,E, SAINT LUCIE COUNTY, FLORIDA,
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C I;:-;.,\q-,~ tf) ~\I~.t >\1l>,~cribed Ldnre me this
, 19
<.Jay of
ROGER POITRAS
('U-:RK ClRf:UIT COURT
N olary Public
By _
O/J0~L(
D.C.
'My Commi89ion '2Xpires
cr" he CXl'cuti.'rl In duplicate and original filed with Clerk Circuit Court, and duplicate with Tn .ABsee8or)
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