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Qeclaratior~ Domfcile ~rnd Citisenship
13~1~(1
TO THE STATE AND COUNTY TAX ASSE5SOR, ~
r,
' Sl. LUCIE COUNTY, ~~oRtoa:
This is my declarstion of Domicile and Citizenship in the State of F(orida thai 1 am ''ling this day in acoordante and
in conformity with Cht+pter 222, Section 222.17, Florida Statutes.
I was forrtiariy a legal residrnt of _~eY'tdOiit _ I~~~~~8 _
(Ci ty) (Sfste)
and 1 resided as -_-Genlxal_ Dtli_v_IY,Y~--- _ However I have changed my domi~ile
(Sireet and Plumber}
to and am and have been a bona fide resident of the State of Florida since __._~4_'~~_ day af
~~4igust_ 19___~,Send I reside a~ 33rd _street A A Grs~n '
(Street and Number)
FORT PtERCE, SAINT tUCtE COUNTY, RORIDA
and this statement is to be taken as my declaration of citi~enship, actual legal residence and domitile in the State of Flarida.
(Inse~t here any pertinent facts, such as sale of properry or business, or relinquishment af employment
at former domicile, removaf of family to new domicile, purchase of home, etc.)
Bntering choldrtn in Jr High School and Elenentar~
~tL AjV EC RDED
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ti___,:,'4;,. + AIJG I 8 PM t: 26
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t. - R~G~R f'C: s i,l~S. CLE~K ~
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I FUR ~ HER CERTI~1f that I wiil comply with all other requirements of a legal resident of this State.
! FURTHER CERTIFY that I have no intention to return to my form~r domi~ile, and I intend to remain in FORT
. PIERCE„~,~~14,j, LUCfE CO[1NTY, FLORit7A, permanently.
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Sworn to and subscribed before me this 1$.~_ day of - ~1•~~•+ , 19
ROaER POfTRAS _
GIRCUIT~t7URt Notary Public
ar ~p O.C. My Commissifln expires
(Ta ba ~xecvt~d in duplicah and ori~ir~aF ~il~d w»h Clwlc ~Cfnuit Court, and duplicats with Ta~c Ass~s*or.)
~~12~ : 5~
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