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De~tfaration ot Domicile ~nd Citizenship
TO THE STAtE AND COUNTY TAX ASSESSOR,
Sl. LUCIE COUNTY, FLORIDA:
This ~s my declaration af Domicile and Citizenship in the State of Florida that I am filing this day in eccordance and
in toniormity with Chapter 222, Section 222.17, Florida StatuTes.
1 was formerly a leyal rasident of ~1~~d0 ~p~1$~ COlO~
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(City) ~STate)
an~ I resided at _ E• _ . However 1 have changed my domi~ile
(Street and Number)
to antl am and have been a bona fide resident of the State of florida since _ day of
- g,p,Y~bQr _ _ , 196~ . and I reside at . 22Q_ oiCeO~i _~YE• .
(Street and Number)
FOR~ PIERCE, SAINT LUCIE COUNTY, ~LORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residen~e and domicile in the State of Florida.
(Insert here any pertinent facts, such as sale of property or business, or relinquishment of employment
at former d~micile, removal of family to new durricile, purchase of home, efic.)
~ F~L AN R~CORD~D
~tering aiild In School 0 0 K
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'05 ~ 5 Qf~ . U 6
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- ROG~ : , ~ " ~~.cr~K
- ' ST. ~UCiE ;,OUt~ i Y.
~ FLO~IDA
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I FURTF{ER CERTIFY that 1 will comply with all other requiremenfs of a legal resident of this State. ,
I FURTHER CER7IFY that I have no intention to return to my former domi~ile, and I intend to remain in FORT
PIERCE, SAINT~LIJCtE`.COUNTY, FLORIDA, permanently.
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, Jol~a I• Li1CSs
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Sworn to and subscribed b~fore me this day of ~~~bar___ 19~..
ROGER POfTRAS - - -
LERK CiRCUlT COURT Notary Publit ~
By D.C. My Commission expires
(to be fxecutad in duplicate and originai ~iled with Clerk C+rcvit Covrt, and duplicat~ witl~ Tax Ass~ssor.)
BODK130 5~1 ~
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