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D~cla~atio~ ot Domicile a~d Citizenship `
. • 1516"~'3
TO TH6 STATE AND COUNTY TAX ASSESSOR, ~
Sl. LUCIE COUNTY, FIORIDA:
Thi: i: my declaration of Domicile and Citizenship in th~ State of Florida that I am filinq this day in aaorda~oe and
in oonformity with Chapter 222, Section 222.17, Florida Statutes.
i was formerly a legal ~esidetr?t of
(Ci . ~ (State)
ar~d I resided at ~ However 1 have chan~ed my domidle
' (Street end Number)
to and sm and hsve been a bons fide resident of the State of Florida since -:,Z~• day of
a • ~ .
, 19 and I reside at
(Street and Number) ~
FORT PI~CE, SAINT LUCIE COUNTY, RORIDA
and this stateme~t is to be taken as-my declaration of citizenship, actual legal residence and domicile in the Stab of Florida.
(Insert here any pertinent facts, such as sale of property or business, or ~elinquishment of employment
at fwmer domicile, removal of family to new domicile, purchase-of home, etc.)
$etabl~~hing re~idence and wi~.1 apply Yor ho~eets4d
?y' .
F~l.EO AN~ RECpRDEO
ST. LUCIiE COUNTY, FLA.
RECORD VERIFIE
. '6t JA~~ 9 AM 9: 41
:
` ~ . 15i6"?'3
~oc~~ '017RA3
~ CLERK CIRCUIT COURT
~ ~
~ ~
I RJRTHER CEitTIFY tfiat I will oomply wiih al) other requirements of a le~al resident of this Ststs.
I fURTHER CERTIFY that 1 have no intention to retum to my former domi4le, and 1 inte~d to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. L"n~~ 9`'
.,k~K lr.c,[t..
% ~ /.r ~it/ ~~~~G
(Name) - -
~y7 1I~~~„J Qvri. ~~~i1,~~
- (Address)
~
~ _ _ -
Swom to and subsuibed before me this dsy of : , 19 .
```ti~1 ~ 11~ J1~ - ,
ROGER POITRAS ~ ~
: . . ~ ~
~ C~RK CIRCUR COURT - . • ~ A- :
w~4;: ~ Publj£4r c,_ p 9~
:•1.~; t10TF4~~I ~ i'~: a._..t, i~.!_.G: Ti~:'it~? 2t ~t
: z 1967
r~,, ~ ~ • ~~Y•.r~i..:5i~9 .iT.."Ca i:i3~~ Z~
By ~.C. ' A j~1j~-:~'~!+~~pi?~fS~~~aMi~FP`~ c.. 8 Grs+tL S~_
~~•'=p~D1.~~ ~'~~y~~7
.j. J.r. ~~r -
(To b~ ~x~aM~d in dupliuh and ari~in~l fil~d wilb Cf~C ~~!'k ~nd dupUcat~ wiTh Tax As~or.)
~ So~c164 n~c~ 27Q _
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