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'~o~K59 fASE 87
Declal'l\~~u~ M~ CitizenWp
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li4043
TO THE STATE AND COUNTY TAX AM1I!HnIt.
ST, LUCIE OOUNTY, FLORIDA:
Th1a 11 Di7 dec1aratloD of Dom1cDe ud Ou-blp lD the State of Flons. that I am f1l1na tblI day in aC'COl'daD<:e
and in corlformll7 with CbapMr 222. SectioD 222.11, FlOrida Statu..
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and I reeded at...:11' ~ 44 ('~ However, I have clumied my domicile
[StNet uad N1JIIlberl s I-
to and am aDd have bMD . boDa 1* reakWat of the State of I"1ori4a .w:. / day of
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FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA.
and this ltatement 11 to be taken u my declaration of clUzenshlp, actuallqal residence and domicile in the State of Florida.
[Insert here any pertinent facts, IUcb .. 181e of property or business, or relinquishment of employment
at fonner domi~ile, removal of family \0 new domicile. purchase of home, etc.)
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11.4.043
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ROGER PC~~~'~~ fl\)R\O~
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1 FURTHER CERTIFY that I will register at my local address when the regLstrntion b:Joks reopen, Bnd comply
with all other requirements of a legtll ~stdent of this state.
I FUr.THER CERTIFY that I have no intention to retUrn to my former domicile, and I intend to remain in
FORT PIERCE, SAINT LUCIE COur.."TY, FLORIDA, permanently, ~
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[Name)
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. ,: ~~:'j..~ ~. t..,:~~);--\~;.:--- Notary Public
: D,Q., .; , My corliin~ri expires.
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(To be execu~ l!1 dupUcate an4 orlrtnal med wtth'{rl~~,mr~'court, and duplicate with Tax A1J~()rl
Sworn to and subscribed before me thl,
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-&OG !TRAS
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