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Declaration of Domicile and Citizenshlp
TO THE STATE AND COUNTY TAX ASSESSOR,
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Sl. LUCIE C~UNTY, FLORIDA:
This is my declaration of Domicile and Citizensfiip in the State of Flo-ida that I am filing this day in accordance ai~d
im m~formity with Chapter 222, Section 222.17, Florida Statutes.
I was formerly a legal resident of Ch~~'~Otte~ North CaI'OlinQ ~
(City) (State)
end I resided at ___9~~-._StatQ_ $tI'eetL____~___._____________ _ . However I havechangad my domic.ile
(5treet and Number)
to nnd am and have been a bona fide resident of the State of Flarida since _~Ld _ day af
Scptember ~q,~~__, end ~ reside at Ss.~~trl ~~ederal Highway
(Street a~d Number)
FORT PIERCE, SAINT LUGlE COUNTY, FLORI~A
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in ihe State of Florida.
(Insert here any pertinent facts, such as sale of property or business, or relinquishment of employment
at former domicile, removal of family to nsw domicile, purchase of home, etc.)
FILE AN ~E~~~~RBflpK
IN i~~~~""`"'
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_ ~ CLER
. ROGER P~11~RAS. TY.
: . ~ . ST. LUCIE COUN _
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1 FURTHER CERTIFY that I will comply with all other requirements of a legal resident of this State.
I FURI'HER CERTIFY that I have no inten4ian to return to my former r~omi~ile, and I intend to remain in FORT
PfERGE, SAiNT LUCIE COUNTY, FLORIDA, permanently.
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(Name)
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(Address)
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Sworn to and subscribed before me th+s ~ f S day of TT ~ T. 1~~
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ROGER POITRA3 . "
CIFRK CIRCUIT COURT Notary ~~I~iC';,~ri~~~'. ~
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By _ D.C. My CQmmission expires ~O~Q° ~
(To be ~xecut4d in duplicats s~d ori~inal ~ilar! with Clerlc Circuit Court, and duplicat~r with Tiac Ass~w~.)
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