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Declaration of Domicile ahd Cilisenship
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TO THE STATE AND COUNTY TAX ASSESSOR,
ST. IUCIE COUNTY, FIORtDA:
This is my declaration of Domicile and ~itizenship in the State of florida that ! am filing 1h;s day i~ acmrdance and
in conformity with Chapter 222, Section 222.17, Florida Statutes.
I was forme~ly a legat resident of _ St• ~lbi~ wCSt Virgiaii
(City) - - ~Siate)
and I resided at _ Rt 1 BO]C 70 . However I have changed my domic,ile
(Street and Number)
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to and am 3nd have been a bona fide resident nf the State of Fforida since 3Q~- - day of
_.IW3,_X ~965-_, and i reside at _ I506__ Geo~gi~ Ave.
(Street and Numkser) ~v f
FORT PlERCE, SAlNT lUCIE COU1+lTY, FLORIDA
and this statement is to be taken as my declaration of citiaenship, actual legal residence and domicile ie~ the StaS~of Fiorida.
(tnsert he~e any pertinent facts, such as sale of pr~perty ar t~usiness, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
~ntering chiid in Element~.rq school
F~LE AND RECBR~Em
chald ~n Jr. High Q~' ' ~.~~~~pOK
. ~r=~,'"% 'S~ 27 AM i0: 2y
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RQ~~f~ t': F::~.:;. C~Er~K
. ,.'y. .:~:.~.-$Y ST. LUClE CUUNTY,
' FLORlDA
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I FUR7WER CERTIFY that 1 wil! comply with all other requirements of a legal resident of this State.
I FURTHER CERTlFY that ! have no intention to return to my former domi~ile, and I intend to remain in FQR7
PIERCE, SAINT LUCIE COUNTY, FLORIbA, permanently.
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~ (Address)
~ 27th ~u$ust
~,$i~v~rn to and subscribed befare me this day of _ , 19_~5
f. ,
ROGER POITRAS
K CIRCUIT OURT Notary Public
c~.c-+El~
~y O.C. A11y Commission expires
(To be ~x~cuted in duplicate and original ~iled with Cierlc Circuit tourt, and dupliests with Tax Oiss~ssor.)
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