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L~ecla~ation ot Domicile and Citizemship
TO THE STATE AND COUNTY TAX ASSESSOR,
Sl. LUGE COUNTY, FLORIDA: ~
This is my decla~ation of Domicile and Citizenship in the State of Florida that 1 am filing this day in aooordance and
in conformity with Chapter 222, Sectio~ 222.17, Florida Statutes.
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I was formerly a legal reside~t of .
(City) (State)
and I resided at _ . However I have changed my domiCile
(Street and Numbe~)
to and am and have been a bona fide ~esident of the State of Florida since day of
..t-~--t.u.t~ 64 ~ 0 7~r~-Z`src- Clc.~-e.._.
~ _ , 19 , and I res~de at
(Street and Number)
FORT PIERCE, SAINMUCIE COUNTY, RORIDA
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and this statement is to be taken as my declaration of citizenship, actual lega) residente and domicile in the State of Ho~ida. ~
(Inurt 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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/ /~L.1%~~cG+~J"' ' " - .
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. FIIED AND RECORD~D`
• ST. LUCIE COUNTY. FLA.
R~CQR~J V~Ri=c~p
18 i
'TO JAN 2 PM 2: y3 ~
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! CLERK CIRCUIT COURTf
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~ I RIRTHER ~ERTIFY that 1 will oomply with all other requiremenh of a legal resident of this State.
1 FURTHER CERTIFY that I have no intention to return to my former domicile, and 1 intend to remain in FORT
PIERCE, SAINT -~~CIE COUNTY, FLORIDA, permanently.
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# Swo~n to and subscribed before me this day of , 19 .
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ROG POITRAS
~ CIRCUIT COURT Notary Public
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f~ By D.C. My ~ommiuion expires
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~ Ro b~ ~x~cuf~d in duplicats and ori~inal ~ilsd with Cltrlc Cirarit Court, and dupliwh with T~x Ass~ssor.)
° R 1g2 PACE 23
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