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Declaratio~ ot Domtcile and ~ Citizenship j~664 i
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T4 THE STATE MID COUNTY TAX ASSESSOR, ~
~ ST. . WCIE COUNTY. FLORIDA: i
This is my declantion of Domicile and Citizenship i~ th~ Stat~ of Fiorlda that 1 am filin~ this day i~ aaoord~na and
In aonfo~?mily with Chapta 42Z. Sectio~ 222.1T, Florida Statutes. '
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1 was formeriy a legal roside~t d~ ~O `
. ~ tCiy) (State) :
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Howevsr 1 have charped my domW~e ~
and I ~ided at ~
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b and am and haw been a ba^a fids ~esident of 1he Stat~ of Florida ~noe daY ~
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~ , 19~'r, and I resids at ~ iL "'J
~t and Numbs~)
lORT MERt~, SAINT LtldE_COUNTY, lLORWA
a~ this :tatem~nt is to bs taken as my declaraYwn of dti~enship, actual lagal r~idenos and domidls in th~ Shte of Horida.
. pnsut here a~ pertine~t fact:, such as sale of prope?ty or busi~ess, or reli~quishment of ~n+ploymsnt
at formsr domicile, removal of family to new domicile, purchass of Fams, etc.)
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~ ~ fi'••.:.;,;,-,.-••~o•'E ~ ROGER POiTRAS. CtERK
: u c t E : ST. LUClE COUNTY. FlORID .
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I RlRTHER C'ERTIFY that 1 wili oomply wHh all oM~er requiremsnts of • is~al rosldeM af /h1s State.
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~ I fURTH~R CERTIFY that 1 have no intention to retum to my former domidle, and 1 in»nd to remsin tn fORT
i PI[RCf, SAINT WCIE COUNTr FLORIDA, permanently.
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, Sw~orn ro snd wbsaib~d bsfore me thh ` day _ 19~ .
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€ D.C. My Corrwniubn ~xpi~
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