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Declaration .of J?~itUe~~ Citizenship
TO 'diE STATE AND COUNTY TAX ASSESSOR,
:-;'1', J.t,nE COt:~TY. FLORlDA:
Thi, is my dedaration of Domicile and Citizenship in the State oi Florida that I am liIinR this day in accordance
a'lIl In nnforlllity with Chapter 222, Section 222.17, Florida Stututes.
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my domicile
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However, I have changed
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day ot
t , ::".1 am and have been a b'J!;n fidl' Tl'sillent ot the S:ate ot FloTula since-
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FOI(T PIERCE, SAI:-tT LUCIE COUNTY, FLORIDA,
a ,: :11;, ,:at"lllcnt i, to be taken as my declaration ot citizenship, actual legal residence and domicile in the State of Florida.
(In'l'rt here any pertinent facts, such as sale of property or business. or relinquishment of employment
lit former domicile, removal of family to new domicIl', purchane of home, etc.)
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I lTH'!"lIER CERTIFY that I will register at my local address when the registration books reopefl, and comply
'".-::!: ;di ,.thr'r requirements of 8 legal resident of this State.
I FUftTHER ('ERTIFY that I have no intention to return to my former domicile, and I intend to remain in
FOln PIEfUT, SAli\T LUCIE COUNTY. FLORIDA, permllnentlj'.
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HOGEft POITRAS
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Cf., r.e ('xtrutrd in dup!ica1e and origil1al tiled ':'fith Clerk Circuit Court, and duplicate .....ith Tax A8Sot'l8Sor)