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Declaration ot Domicile and ~itizenshfp 1:3~~5~%~~
TU THE STATE AND COUNTY TAX ASSESSOR,
Sl. LUCIE COUNTY, ~LORIDA:
This is my declaration of Domic~le and Citizenship in the State of Florida that I am filing ihis day in ectordance and
in conformity with Chapter 222, Section 222.17, Florida Statutes.
I was formerly a lEgai resident of ~id~11 - ________.~'.~,.S2.r~.fl..~___~-_- -
- - (C~ty) (State)
and I resided at g30 N. E. 142 ~tr-get However I have changed my domiCile
(S!reet and Number)
to and am and have been a bona fide resident of the State of Florida since 3 . day of
April 65 422 Cononut Avenue, Port ~t.Lucie
_ . _ , 19__ . . . , and I reside at _ .
(Street and Number)
FORT PIERCE, SAIN'~ LUCIE COUNTY, FLORIDA
and this statement is to be taken as my declaration :+f citizenship, actual legal residence and domicile in the 5tate of Florida.
(Insert here any pertinent facts, s~~ch as sale ot oroperty or business, or relinquishment of empleyment
at former domicile, remova! of family to new don~i~ile, purchase of home, etc.)
E~tablishing residence F1LEp qNC REC
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!~URTHER CER7IFY that f will comply with al) other requirements of a legal resident of ttsis Stafie.
I FURTHER CERTIFY that I have no intention to return to my former domicile, and I intend to remain in FORT
PIERCE, SAi~1T LUCiE COUN7Y, FLORIDA, permanently. , _
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.s'• ( me)
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• {Address)
. .
, f,,,.`~ 2~ Od+~ober 65
9inr~jj?~t~ a~rcj ~scribed hefore me th~s day of , 19 .
. .
ROGER POITRAS - -
IERK CIRC COURT Notary Public
gy _ D.C. My Commission $xpires
(To be executsd in duplicate snd ~riginal filed with C1erk Circuit Court, snd dupliwte with Tax Assessor.)
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