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Declaration ot Domicile and Citisensiiip '
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TO THE STATE AND COUNTY TAX ASSESSOR,
S~. LUCIE COUNTY, F10RIOA;
This is my decla~ation of Domicile and Citi=enship in the State of Florida that ! am filin~ this day in ec~acrdance and
in conformity with Chaptet 222, Saction 222.17, Florida Statutas.
t was fermerly a legal ~es+dent of Vicksrurg Michigan
ICiN) (Sta»)
and I~e:~ded ar 12002 Sprinkle ROad _L___. ~~„~ever 1 have changed my domivle
(Street and Number)
to and am and have b~en a bona fide resident of the Stab of Florida since Sth day of
-~~s'.C.LmI?eL_ , 19~LZ, and I reside at 356 1~lid W8y
(Street and Number)
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fORT PIERGE, SAINT LUCIE COUNTY, FIORIDA
an.-~ this statement is to be taken as my declaration of citize~ship, actual Icgal residence and domicile in the State of FlorFda.
(Insert here any pertinent facts, such as sale of property or business, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.) ~
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Entering children in school
FtLED ANO RECORDEO
ST. LUCIE COUNTY. FLA. (
. i2c.CORD V~RIFIEO ~
16 190
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..U:,.:~i- ~~l}~TR: s
CLERK CIRCUIT COURT
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1 RIRTHER GERTIFY that 1 will oomply with a!I other ~equ~rements of a le~al resident of this State. - i
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I FURTHER ~CERTIFY that I have no intention to retum to my former domitile, and I intend to remain in FORT j
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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Sworn to and subxribed before me this 2nd day ot _ Jan~tarq , 19-St$.
ROGER POITRAS
CLERK CIRCUIT COURT . Notary Public
BY D.C. M Commissio~ ex ires
Y P
- (1'e b~ ~x~cu~+d in duplicab snd ori~inal Rl~d witb CfKlc prwit Court, and dupliuh with Tax Asa~or.)
B~x 169 Pac~ 2631