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Oecla~atlon ot Don~icile and Citizenshlp ~
TO THE STATE AND COUNTY TAX ASSESSOR,
51. IUCIE tOUNTY, FIORiDA:
This is my declaration of Domicile and Citizenship in the State of Flo~ida that 1 am filing this day in aoo~rdanos a~d
in conformity with Chapte~ 222, Section 222.17, Florida Statutes.
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I was formerly a legal resident of Cincinnati _ Ohio f
tCiy) - (State)
3288 Baeawood Leae ~
and 1 resided at _ _ However I hsve changad my domityle ~
(Street and Number)
to and am and have been a bona fide resident of the State of Florida since AugLlgt day of
_ , i9 6T, a~d ~ res~de ar 3131 So. Federal Highway
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, RORIDA i
and this stateme~t is to be taken as my declaration of citize~ship, actual lec~al residence and domicile in the State of Ho~id~. ~
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(Insert here any pertinent facts, such as sale of property or busineu, or relinquishment of employme~t `
at former domicile, removal of family to new dQmicile, purchase of home, e~tt.)
Establishing reeidence
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FtLED ANO RECOROEO':
ST. LUCIE COUNI'Y. FLA. `
RrcoRn vERi~iE~
•1'~~2
'69 JUN 19 AM 9: 02
~~5~
i~OG . ? OITRAS
CIERK CIRCUIT COURT
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I RIRTHER ~ERTIFY that I will oomply with all other requirements of a leyal res'~dent of this Stste.
I FURTHER CERTIFY that I have no intention to return to my former domicjle, and 1 intend to remain in FORT
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PIHtCE, SAINT LUCIE COUNTY, FLORIDA, pe~manently.
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Sworn to and subsuibed before me this 1~. day of Ju~e , 19~4.
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ROGER POITRAS i
CLFRK CIltCUR COURT Notary Public ~
- g O.C. My Commiuion expires ~
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~ Re b~ ~c~cuNd in duplicat~ and ori~inal fil~d wilh Clwk Cirwit Cou~i. and d~lieah wilb Tax A~t~ora
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