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Declaration qf. o..mcile and Citizenship
. ~':~ '",LU~~[ COUNTY.: r~_A:.
J14267
TO TIlE STATE .'-\ND COUNTY TAX ASSESSOR.
ST. LUCIE COUNTY. flA>RIDA:
This is my declaration of Domicile and Citlzenshlp'ln the State,2f Florida that 1 .am fiilng this da';' In accoroance
and in conformity with Chapter 222. Section 222.11, Florida Statutes.
I was formerly a legal resident of
M.iddlevil18
[City)
New_.X ork
State
Lake Roust) Hot.el
[Street and Nwnber)
to and am and have been a bona fide resident of the State of Florida si!1ce
Ja nua ry 62
19_ _, and I reside at ___
and I resided 3.t
However, I have changed my domicile
1
day of
~~rt Pierce Het e1
[Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA,
and this state:n~nt is to be takcn as my de~laration of citizensh ip. nct~al legal residence an] domicile in the State of Florida,
[Inscrt herc any pertine~t facts, such as s3b of property or business, or relinquishment of employment
at former domicile, removal of fanlily to new domi die p:lrchase of home, etc,]
.....
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For Homestead Purposes
l14267
r" rn "ID F'I En~ ~ OEfI
rlLlU 111'0 1\ \"UI\ lJ
Ii: .--Official. ~J 1GOK
ISS3 Hn~ 27 AM 9: 58
ROGER POITf(AS, Cl.ERK ,~J.J
81. LUCIE GOUIITY. FLORIOA rvJ'
OJ
I FURTHER CERTIFY thet I will register at my loc31 addre5s \I.'hen th~ registration b~'ok5 reopc,",. and comply
\\'ith all other re:luircmcnts of a legal resident of this state.
I FCRTHE~ t;ERTIFY that I hc.v~ no htention to re turn to my former domicile. nnd I intend to rc:nain ;n
"",'it.", -'
FOR, T ,~.I~~~.1>,~, 0' "~CIE COUNTY. FLORIDA, pcrmane~ntlY' ,~ C) 0~
" \\" .....0... U- '.. '. '-- '
'::' V ,.~(.\\!'t .j.... ,?,,\ - "L- _,......~ ( L.-L-~
, ,'t;, .. "c/' ,,' . .
; ... L ~;.: j; "'\ ':. [Name]
: V.-_,~~ZrD ..'~) J F~o no 1aJ-"llrdmore. .-.. --.- - -
,....." '.'~'... '..~:' [Address]
. J ".. .. -' .,' <:. ,........ .:;
"(j .......... ,', \
Sworn 'to arld }s6b~~b'el before me this
27
~X~h
. .__~ ] 9-_63
:lay of
P.OG r:~ POITRAS
CLEi~I~ nRCCJT CO~;~T
3y _._~-r-~~ii____-
:';'otary PubEc
-_ D,C,
~,1y C~missior, c';pircs .---..------~
[To be executed In duplicate and orh'ln 11 tile 1 with C Jerk Circuit Court, aud dllplkate with Tax As,l'S..orl