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~la""~Lcet~~er~,~ Citizenship
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.113958
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TU TilE STATE AND COUNTY TAX ASSESSOR,
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ST, LuCIE COUNTY, FLORIDA:
This is my declaration of Domicile and Citizenship in the State of Florida Urat I 8m filing It.is day in accordance
and in conformity with Chapter 222, Section 22.2.17, Florida Statutes.
I was formerly a legal resident of
........
Roanoke County
(City)
State
Va 0
<In! I n.,j,!ed at
Ht 1
Box 89
rto8noke
(Slreet and Number)
. However, I have changed my domicile
II an,l am and hR\,(' been a b~na fide resident of the Slate of Florida since
13th
day or
uecenber
I:J~ and I reside at
4702 Elm Ave..
'(Steet and Number)
FOHT PIERCE. SAINT LUCIE COUNTY. FLORIDA,
(I:~,I Ihis statement is to be taken as my dl'Claration of citizen,hip, actual legal residence and domicile in the State of Florida.
(Insert here any pertinent facts, such as sale of property or business, or relinquishment of employment
l\t furmer domicile, removal of family to new domicle, purchase of home. etc.)
Anulying for hOJ:.,estead
1'\3958 f\\.tO ~NO RlCORO[O
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J FCRTIIER CF.RTIFY that I will register at my local address when the regi~tNltion books reopen, and comply
',':i,!; al! dh{'r rcquirelr,ents of a legal resident of th~ State.
I FURTHER CERTIFY that I h1lve no intention to return to my former domicile. and I intend ({) remain in
1-'01:1' I'IEnO:. SAI~T LUCIE COUNTY. FLORIDA, permanently.
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(Name) .:;;/
CrE:uSE;Y
','il:.<l'ren L.
(Address)
~~\'.():'n ~() an,1 ~ubseribed before me this
13
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'1f6taI'y Public
6:5
day of
__,19
ROGER POITRAS
. /;:;f.ERK CIRCUIT, COURT
B'Z;,=,-~f'/ ~~L7
D,C.
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~T" he executed in dupllcllle snd original filed with Clerk Circuit Court. and dnpUcate "ith Tax MSESllOT)
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