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Declai'ation or~c~l~u~ ~\~hip
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114092'
TO TilE STATE AND COUNTY TAX ASSESSOR,
:-,T. Ltca: COl':-:TY, FLORIDA;
This is my declaration of Domicile and Citizenship In the State of Florida that I am filing this day in accordance
and in l'lInformity with Chapter 222, Section 222.17, Florida Statul~s.
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I was fornH'rly 1\ legal resident of ~ ~ ~
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State
changed my domicile
. However, I have
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day 01
t" "llll am B!ld \illve bc-en a b:>nll tide resilIent of the Slnte of Florida since
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'rfi[;T PIERCE, ;.\(NT LaE COUNTY, FLORIDA,
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i4. aad I reside at
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(Steet and Number)
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a::d this ~ti\temcnt is to be taken as my declaration of citizenship, !tcll'al legal residence and domicile in the State of Florida.
(In'ert here any pertinent facts, such liS sale of property or business, or relinquishment of employment
at fonner domicile, removal of family to new domicil", purchase of home, etc.)
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(/ /fFl~RJll~'R C ERTI FY that I wiIl register at my locsl
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with all ..ther requirements of a legal resident of this State.
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l ICtal pRECOliDED
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Si, LUCIE CDOull~rt\~~~:, CLJ.. c/
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address when the r"!gistration lxJoks :-eopeD, and comply
I FURTHER CERTIFY that I have no intention to return to my former domicile, and I btend to remain in
FORT 1'II-:Rf'F:, SAINT LTJCIE COUNTY, FLORIDA, permanently.
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Rec. ~ /VcaIJMhN'N
(Address)
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, 0' I; ; ..J ~: Notary Public
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(To he c:o;ecuted In duplicate and \lriglnal flied with Clerk Circuit Court, aDd d'lplleate with Tax A4seM0r)
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~w()rn '0 an<1 ,ubscribed beLre me thi,
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ROGER POITRAS
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