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Declaratioll'pJ" ~ll1hH~ 'faI)d Citiz~n8hip
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11,13~)8
TO THE STATE AND COUNTY TAX ASSESSOR,
;;;T, LUCIE COUNTY, FLORIDA:
This is my declaration of Domicile and Citizenship In the State of Florida thut I am filing thi.'l day in Qcrordancc
and in conformity with Chlipter 222, Section 222,11, Florida Statutes.
I was formerly a legal resident of
Lo~~ Island
[City]
New York
State
and I
'd d t 8 FOISter Lane
reSl e a
[Street and Number]
_Ho.....ever. I have changed my domicUe
to and am and ha\'e been a bona fide resident of the State of Florida since _2 ~t/h " ",' I
Y--<.-b-L......~.(..d.- ^-~ ~ ~t '
March 63 Lak cd P k
19__. and I reside at __.ewo ar
[Street and Number]
day of
....
FORT PIERCE, SAINT LUCIE COUNTY. FLORIDA,
al:d this statement is to be taken as my d:!claration of citlzensh ip, actual legal residence and domicile in the State ot Florida,
[Insert here any pertinc:1t facts, such as s'lli'! of property or business, or relinquishment of employment
at former domicile, removal of family to new domi dIe purchase of home, etc,]
. .
Entering Susan Young in the 1st grade
" ~ich8rd in the 2nd grade
.l1439t1
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:~. Offi~i~rR~~;t' ':~~,'"
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r.; 1 r :.; 3
ROGER rCI i;\:',:~,:: "
S T L U C lEe ,', I' ',,;,' :': -,.. ,I
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I FURTHER CERTIFY that I will register at my local address when the registration b:Joks reope:1, and comply
with all other requirements of a legal resident of this State.
I FURTHJ::R CERTIFY that I have no intention to return to my former domicile. and I intend to remain in
FORT PIERCE, SAINT LUCIE COUNTY. FLORIDA. permanently.
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[To be e..'(~uted In duplicate and orlr1nl'il filed mth'.~'t.~
. ""~~""_.~ : "~"'.' .'
[Address]
A pr 11
63
19~__
Sworn to and subscribed before me th;~
ZOG POITRAS
CLERK ~
3y . c<~~
Notary Public
expires
and duplicate with Tax AssesSor]
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