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De~laration o~f Domicile and Citizanshlp ~ ~~4~
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YO THE 51'ATE ANb COUNtY 1'AX ASSESSOR, •
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Sl. LUCIE COUNTY, FLORIDA:
This is my declaration of Domitile and Citizenship in the State of Floride that I am filing this day in accordante and
in conformiry with Chapter 222, Section 222.17', Florida Statutes. '
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Colusbua Ohio "
I was formerly a legal resident of . _ ~
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(C;ty) (State) ~
However I have chan ed m domicrle
and I residcd at .-_1!~Q4. _ GaSt.. g0~-- • ~4
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(Sireet and Number)
to and am and have been a bona fide resident of the State of Florida since 29th day ot ~
Ju . 19~$.__, and I reside at 1709 PiSCO AVt~~ ~
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FORT PIERCE, SAINT LUGIE COUNTY, FLQRiD/i
and this statement is to be taken as my declarat~~n of citizenship, actual legal resid~ence and domicile in the 5tate of Flarida. ~ ~
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(Insert here any pertinent facts, such as sale of property or business, or relinquishment nf employrrsent
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at former domicile, removal of family to new domicile, purchase of home, etc.) ~
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nterin~ child i~ school . a
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ROGE" ~'~:l i F;AS. C ~
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ST. LUCIE COUNTY, ~ y
FLORlDA =
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!~,...!-4~.. C~...., .~,a~ ~ w~~~ ~o~nN~y with all other requirements of a legal rssident of this State. !
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I FURTHER CERTIFY that I have no intention to return to my former domiSile, an~ I intend to remain in FORT ` Y
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PIERCE, SAINT LUCiE COUNTY, FLORI~A, permanently. ~
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{Name) ~ -
Patti Barber ~ 5
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Sworn to and subscribed beforr ~;i~ltisr~._____.2.L~th__ day of A+~ o~st , 19~~. f
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ROGER POITRAS , : Cs ~ r',.+ r. - • ' ~ _ -
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~LERK CIR COURT _ ° . ~ Noiary Public ~
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gy D.C. h1y Commission expires '
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(To b~ ox~cvr~d in civpiisa»~ sni! ~hngiaal f'rkd with Cis?k Circuit CauR, and doplicata with Tax Asses~or.)
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