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Declarati~ ~f Q~~~~4Ai:tizelUhip
TO Till-: STATE AND COUNTY TAX ASSESSOR,
:,T, u;cn: COUNTY. FLORIDA:
This is my dl'c1aration of Domicile and Cith:enship In thtl State of Florida that I am filinlt this day in accordance.
and in l'cOnformity with Chapter 222, Section 222,17, Florida Statutes.
I was formerly a
legal resident Of~~~
- (Cit)')
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State
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aliI I rl"ide" at /y~ 4 c:? "/~
However. I have chal1ged my domicile
~ Slrcet and Number)
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day 01
(" "'1I1 alll :lnd have becn a bClJ1a fide resident of the State of Florida since
'7Jz7
FORT PIERCE. SAINT LUCIE COUNTY, FLORIDA,
I~":<" . and I reside at~..2 k 0l765/-c:fd
C~~;:.~p~
a~;d Ihi" ,tall'ml'n~ i~ to be taken as my declaration of citaenship, actual legal re~idence and domicile in the State of Florida.
(Inq~rt here an)' pertinent facts, such as sale of propHty or business, or relinquishment of employment
lit former domicile, removal of family to new domicil', purchase of home, etc.)
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ROG ER Pl'~~\~~' {\.~R\~ ~ n
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I FU P.T1IER CERTIFY that I will re-gister at my loeal address when the registration books reopen, and compl,
wilh all dhl'r requirements of a legal resident of this State.
I FURTHER CERTIFY thltt I have no intentkn to return to my former domicile, and I intend to remain in
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA. permanently,
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(Keme)
(Address)
S"':01'!1 to an:! ~ubscribed bef',re me this
/8~ day of. J/J~ ,19 ~ 3
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:: .- , -', 0 : Notary Public
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'; ~ 6:c: ':".' My" eo~~lon explna _
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filed with 'Cterk Circuit Court, and dupUcate with Tax ~)
ROGER POITRAS
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(1'1) he executed In duplicate and original