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Decla~atio~ ot Domicile and Citlzenship 14,~~4
TO THE STATE AND COUNTY TAX ASSESSOR, ' ~
51. IIKIE COUNTY, FLGitIDA:
This is my declaratio~ of Oomicile and CitEzenship In the State of Florida that 1 am filing this day in eooordenos and
in oonformity with Chapter 222, Section 222.17, Florida Statutes. -
1 was formerly a legal ~esident of p~ttsbur pa
(City) (State)
and 1 resided at _ 113 _ GrCeOSidc AVl. ~Wevef 1 have chan~ed my domic3le
(Street and Numbe~)
to and am and have been a bona fide resident of the State of Florida sinee 19th day of
~ August 66 SOS Sandia Drive ~ Port St.Lucie )
, 19 , and I reside at
(Street and Number)
FORT r1ERCE, SAINT LtlCIE COUNTY, RORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Florida.
(Insert here any pertinent fads, such as sale of property or business, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
~ntering child in school
• F~~ED AN~ RECORB~p
sT ~~~~E COUNTY
Bstabiishing residence RECORO VERlFtED~'
'6S ~j~~T 24 pM 12.
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CL f.p'~~~~~~5
ERK C(RCUI R
. T COUaT
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` 1 FURTHER CHtTIFY that I will aomply with all other requirements of e leyal resident of this State.
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1 FURTHER CERTIFY that I have no intention to retum to my former domicjle, and I intend to remain in FORT
PIERCE, SAINT IUCIE COUNTY, FLORI~A, permanently.
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~~~~~y~UC~~or1~~,a~l~d subsuibed before-me this 24tb day of AuguS'! ~ 19 66
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ROGER POITRAS
CiRCU1T ~URT Notary Public
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~ By Z~ D.C. My Commission expires
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Ro b~ uacut~d in ~hrpljuh and oriainal fibd whh CIKk Cinuif Couet, and dupljcab wifh Tax Ap~aor.)
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