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Deciaration ot Domicile ahd Citizenship
TO THE STATE AN~ COUNTY TAX ASSESSOR,
Sl. IUCIE COUNTY, FLORIDA:
This is my declaration of Oomicile and Citizenship in the State of Florida that I am filing this day in accordance anci
in coaformity w~rh Chapter 222, Section 222.17, Florida Statutes.
l Q/ .
~ was formerly a legal resident of -
~~;~yy (State)
~i~i~C /~~y However 1 have changed my domicjle
and I resided at _ ~
(Street and Numt~er) ~
to and am a ve bee~ a bona fide resident of the State of Florida since d1y of
. . 19 and 1 res+de at ~'~'2'~ ,
(Sheet and Number)
FO IERCE, SAINT LUCIE COUNfIf, FLORIDA
and this statement is to be taken as my declaration of citizenship, adual lega{ residence and domicile in the State of Horida.
(Insert here any pertinent fads, 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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~!:.EO ~rJ~ R~CORDED ~
LUC~~ ~~Ut:TY. Fi.A. t
ri:--~ :c,~-;i s
, ~~`~3~ -t
26 p~ ~ ; 57 Y~
- ' ~ ~
• ~L,t~ ;~S ~7
~ ~i.e~K ~;r::':,'r~ COURT
1 FURTHER CERTIFl( that 1 will oomply with atl other requirements of a lega! resident of this Stete.
I FURTHER CERTIFY that 1 have no iniention to return to my former domiCile, and I intend to remain in FORT ~
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
~
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~ : . ~ r•' : ' - (Address) ~
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, Sworn to.and subscribed before me this day of ~ 19~v ~ s
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ROGER POITRAS `
LERK CIRCUI COURT Notary Public
~ ~~.~9Y~G~~ M Commission ex ires ~
gy( _ D.C. Y P
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(To bs axecuted in dupliute and orig+nal filed with Clerk Circuit Court, snd dupliut~ with Tax Ass~ssor•)
gao~ PAGC 1444 ~
~ No. 13 -