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Declaratfon ot Domiciie and Citizenship
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TO THE STATE ANC COUNTY TAX ASSESSOR, 1 '
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ST. Lt1C1E COUNTY. FIORIDA: l ~
ti of Oomicils and Citizenship in the State of Florida that I am filin~ this day in actordanos a~d ~
This is my declara on
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in oo~formity with Chaptet 222, Section 222.17. Florida Stetutes.
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I w~s formerly a leyal ~esident of - ~s~)
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and 1 rosided at lj~ St~t• Rd• How~ver 1 have chan9ed my domid~e ~y'
(5naet and Number) . ~
l ~E IId day of
b ~nd ~m and have been a bona fids resident of the State of Florida sinae -
Oatobsr , 19 4s, and ~ mside e~ ~b01 YelrM ~ le Ro~d
- . (Street and Number) .
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~ naecE. s~?ir~ wciE couNnr, aauo~ .
snd this statement i: to be tsken as my deciaration of citizenship, actual le~al residenoe and domidls in fhe Stats of Florida•
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(Insert here any pertinent facts, su4h as sale of property or bu=iness. a relinqui:hment of employment r~:
at former domicite, removal of family b new don+icite, purchase of home, etc.)
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ePP17~6 ror honeste~d 1~~3
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- f!~ F ~~D RE~OPO~D x=:
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tiu a~';4,: - 1964 Jafd I 5 P~4 2: 25
';vs•Cvuu~1.~. Lat~•4~.'. '
~ ~ q•.''s~~L,`'• . ~`:T'~?Yti~ ~ ROGE~; POITRaS. CLcRit = -
~ . . ~ , .~~=;::<r ~T. LUCIE CDU~iIY. FLORIOA _
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• 1 FURTHER CER'TIFY that 1 wilt register at my local eddrass when the registrohon books reopen, and oomply with
all other requirements of e legal rosident of this State.
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F I FURTFIER CERTIFY that I have no intention to mtum to nsy fomner domic~le, and 1 intend to remain in FOiCT
p16RCE, SAINT LUCIE COUNTY. FLORIDA, permanently. -
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Aadrew 1dao~eres
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S~worn to and wbsaibed bsforf ms this ~Y ~ - '
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