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DeClaratio~ ot Oomicile and Citizenship
TO THE STATE AND ~OUNTY TAX ASSESSOR,
Sl. WCIE COUNTY, FIORIDA:
This is my declaration of Domicile and Citizenship in the State of Ftorida that 1 am filing this day in accordante and
i~ tonformity with Chapter ?22, Sectio~ 222.17, Florida Statutes.
1 was formerly a legal ~esident of ZO~ Ieland 8ew York
(City) (State)
and 1 ~es~ded af 42 ~BSt First 3treet Freeport ~Wever I have cfianged my domicale
(Street and Number)
to and am and have been a bona fide resident of the State of Florida sincc 2nd day of
gugust , 19 69 and 1 reside ar 421 Tranquilla Ave
(Street and Number)
FORY PIEIECE, SAINT LUCfE COUNTY, FLORIDA ~
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Ho~ida. ;
(Inserf here any pertinent facts, such as sale of property or business, or relinquishment of employme~t ~
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at former domicile, removal of family to ~ew domicite, purchase of home, ett.)
Establishing residence and applying for homestead
FIl.EO .~Np R~~ORDED ¢
ST, LUCiE CCU.`:TY, FL,•,. ~
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I FURTHER CERTIFY that I will comply with all other requirements of a legal resident ~of this State.
• 1 FURTHER CERTIFY that I have no intention to return to my former domicjle, and 1 intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. ,
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~,~o and subscribed before me this 9th day of Feb~ar3C , 19_~
RO~iER POITRAS
. K CIRCUIT COURT Notary Public
By D.C. My Commission expires
(To be sxecuted in dupliut~ snd ori~inal fil~d with G~rlc GrcuFt Court, and duplicat~ with Tax Ass~saor.)
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