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Declaration of Domicile- and Citizenship
TO TilE STATE AND COUNTY TAX A..."'SESSOR,
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BO :.\l~ 4fj8
=,T, Ll~CII-; COUNTY, FLOIUDA:
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This is my declaration ot Domicile and Citize:lship in the State of Florida that I am filing this day in accordance
and in conformity with Chapter m, Section 222.17, Florida Statutes.
Bo~tord ~
I was formerly a legal re5idcnt ot_~-- - ___u_____'
(City]
lla 88 .
State
and I resided at
Ohapman Road
___. However, I have changed my domicil;?
(Street and Number]
2
to and am and have been a bolUl. fide resident of the State of Florida shce
Apr11
day of
1012 Ch1po1a Road
63
19_ _, and I rl'side at
[Street find Nu.mberl
fo-ORT PIERCE, SAINT LUCIE COUNTY, FLORIDA,
ar.d this st:ltement is to be taken as my d~claration of citizcnsh ip, actual legal re3idence an:! domicile in the State ot Florida.
[Insert here any pertine:lt facts, such as S'lle of property or business, or relinquishment of employment
at forn1er domicile, removal of family to new dO::li :'lle p'lrchase of home, etc. ]
Eatab11ahlng residency
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I FURTHER CERTIFY that I will register at my lOCal address when the registration b~oks reopen, <lnd comply
with all other requirP.rllents of a legal resident of this State.
I FURTHER CERTIFY that I hav::! no intention to retlun to my former domicile, and I intend to remain in
FORT P~q~; S~INT LUCIE COUNTY,
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FLORIDA,
permanently. Q~ M ~
c/ [Name)
John W. "iokers
(Address]
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Sworn lq Oa~' s~b'sc.ribed before me thi~
April
_~___.~~ 19__-&3
10
:lay of
ROGr:Il POITRAS
CLERK CIRCCIT COUnT
3y __(~ ~I
----~----~ --~- --. - - --- --._- ------------
; iotary Public
D,C,
~ly Commission expires
[To be c'xCoCuted In duplicate and orlglna.l filed with Clerk Circuit Court, and duplicate with Tax Assessor]
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