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; Decia~atlon ot Domicile and Citi:enship 1~440 ~
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; TO THE STATE AND COUNTY TAX ASSESSOR, '
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? ST, IIICIE COUNTY, FIORIDA: ~
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t This is my declaration of Domicile and Citizen:hip in ths Stats of Florida that 1 sm filin~ this dsy in aooonlanoe and ~
' in oonformity with Chapro~ ~22, Section 222.17, Floritia Ststutes.
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1 was forme~ly a layal resident of a~~~~ - 4~ •
(City) (State) ~
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~ and 1 resided at 14SS E=periaent St. I have d?anged my domidle !
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; tv and am a~d have been a bona fide msident of the State of Florida sinos lat' day of ;
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~ AI~RIl~ , 19_~, snd I roside at 1510 3. 88fi.~1 St•
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~ (Streef and Number)
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i~ ~ORT M~, SAtNT LtJCI~ COUNTY, RORIDA -
~ and this statement is to be taken as my dedaration of citiz~enship, adual leqsl residenoe and domidie in the State of Horids.
' pnsert here any pertinent facri, such as sale of properfy or business, or relinquishment of emptaymeM
1 st former dorr~idls, romovai of family to new domidle, purchase of home, etc.)
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~ . : t;~~. 1~~440
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~ ' ' ~EUO~E"GO'' ~ ROGER PQITRAS.~t~RiC :
` ~ ~ ST. LUCIE CGG?~TY, FLO410A ~
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~ 1 fURTH~R CER?IFY that 1 will register at my lotsl address when tt~e rogishation books raopen, and oomply with :
al! other roquirements of a le~al rosident of this Stab. •
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1 RJRTHER CERTIFY that I have no intention to rotum to r»y former domidle, and I intend to remain in FORT `
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~ PIERCE, SAtNT WCIE COUNTY, FLORIDA, permanently. :
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~ a:~~~ ~ Syi qr~i to and wbscribsd bsfore ms this 1~8th d~y .TAIQUA~ 19~. %
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8y D.C. My Commission expires ~ •
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(Te b~ in duplieah asd ~i~intl Al~d wilb • CtNk Cie+aeif Cou~f, and dvpticaN with Tax Assessor.)
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