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Declaration ot DOmicile and ~itizenship
TO THE STATE AtVb COUNTY TAX ASiESSOR,
Si. LUCIE COUNTY, FIORiDA:
This is my deelaration of Domicile and Cit~aenship in the State nf Florida that I am filing this day in accordance and
in conformity with Chapter 222, Seclion 222.17, Florida Stafutes.
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I was formerly a legal resident of
{City) (State)
lj~ 1Ceube~8 Stx`eet However I have chan ed m d~miCile
and 1 rasided at - 9 Y
(Street and Number)
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to and am and have been a bana fide resident nf The State of Florida since day of
Nov~enber 65 195 Cel~stia Canrt, &i~er Pax~lc
_ _ _ , 19__ , and I reside at
- -
(Street and Number)
FORt PIERCE, SpINT LUCIE COU~ITY, FLOIi1DA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the 5tate of Florida.
(Insert here any pertinent facts, such as sale of property or business, or relinquishment of employment
at former domitile, removal of family to new domicile, purchase of home, etc.)
~terin~g Bruce in 9t~ ~ra e
M, Bradford in 5th ~ade D'~ r1 ~ R
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I~URTHER CER7IFY that I will comply with all other requirements of a le~al resident of this State.
I FURTHER CERTIFY that I have no intention to return to my former domi~i~e, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORfbA, permanently.
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~worn to and subscribed be~ore me this day of XOVanbmr 19 ~j
ROGER POITRAS - -
C K CIRC CQURT Notary Public
By _ D.C. fV~y Commission expires -
(To be exstuted in duplic~te and originaf f~Ied wiffi Clerk Circuil Court, and dupiieat~ with Tax Assvs~or.)
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