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D~laration ot Damicil• and Citlzenship
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; TO THE STATE AND COUNTY 1AX ASSESSOR, i r7 S;~`~ ~ ~
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f 51. LUCiE COUNTY, FIORIDA: ~ <:g~'~
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Thit is my declaration of Oomicile and Citizenship in tha State of Fiorida that 1 am fi~~ng this day in actordance and -~1-
in tonformity with Chapter ?22, Section 222.17, Florida 5tatutes.
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.Ianesville Wia~conain ~ ~ ~4~`~
I wes formerly a legal resident of _ , . _ _ _ :
(City) - ($tate) - ~
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R4ra1 Route 1 : R ~
and t resided at - - - - . . Hawever I have changed my domitile ~
{STreei and Number) , I
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to and am and have k~een a bona ficle resident of the State af Florida since ~ls_ ~ day of ; o,
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June 65 6A4 S 24t~ Strtet > 4~
- . _ 19._____, and I residt at t ; g'` :
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ZStreet and Number) ' ; '
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FORT PI~ItCE, SAINT LUCIE COUI+lTY, PLORiDA ~
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and this statement is to be taken as my declaration of citizenship, actual legal r4sidence and domicile in the S`~!e of ~iorida. ~ j
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(Insert here e~ny pertinent fads, such as sale of property or business, or relinquishment of em~~loyment fi ~
at former domicile, removal of family to new domicile, purchase of home, etcJ w' r:~ ~
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fintering children in Ist zr~d 2nd gridea E
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1 FURTHER CERTIFY that I will comply with a11 other requirements of a legal resident of this State. ~
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I FURTHER CERTIFY that I have no +ntention tn retum to my former domi4ile, and ! intend to remain in FORT (
• PIERCE,, S/~1~1i' LUCtE ~OUN7Y, FLORIDA, permanent(y. . ~
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5worn to and subscrib~d betore me this day of ~__v , 19 . i
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ROQ~ POITRAS .~'.Gl ~ ~ .
~ Ct~RK CiR iT COUtltT Notary Public ~ i
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, ay D.C. M,y Commission expires ~ ( ~
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(To b~ ~xsevt~d ie dvptiut~ and o?iginal ~elad with Cl~lt Circvif Court, and duplieat~ w~iti~ Ta~c Ass~or.) :
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