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. Dacla~atio~ ot Do~nicil• a~d Citizenship ~ 148461
TO THE STATE ANO COUNTY TAX ASSESSOR, _
Sl. IUCIE COUNTY, FLORIDA: .
This is my declaration of Domicile and Citizenship in the State of Flo~ida that 1 am fili~y thi: dey in scoo~danos and
in oonformily with Chapter 222, Section 222.17, Florida Statutes.
I was fo~merly a legal resident of ~~~r~ V~
(City) (Stat~)
and 1 resided at Howevsr 1 have chanqed my domidle
- (Street and Numbe~)
td and am and have been a bona fide resident of the State of Florida since __~Q~ ~Q~6 ~'1r~
~
. 19 and I reside at ~.~~'7 ~r'~~4v/'"~ ~ 1~~
(Stroet amd Number)
I'ORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
and this statement is to be taken as my declarotion of citizenship, actual legal residenoe and domicile in ihe State of Horida.
(lnsert here any pertinent facts, such as sale of property or business, or reiinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
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I FURTHER GHtTIFY that I wil! aomply with all othe~ requirements of a leqal resident ~this State.
I FURTHER CERTIFY that I have no intention to retum to my former domic~le, and I intend to remain in FORT
PIERCE, SAlNT LUCIE COUNTY, FLORIDA, permanently.
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Sworn to and subsc~ibed before me this day of ~ e~- , 19~Q_.
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RO~iER POITRAS ~ ~ .
:
CLFRK CIRCUR COURT . `t • ~ . Notary Public
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(To b~ ~x~cuh.d in duplicat~ snd ori~inal fil~d wilii~;C~t~~~Y~ER, ibd_ dupliat~ with Tax AtMS~o~.)
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