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Declaratio~ ot DomlCile and Citizenship ~
TO THE STATE AND COUNTY TAX ASSESSOR, '
Sl. LUCIE COUNTY, FlORIDA:
This is my declaration of Oomicile and Citize~ship in the State of Florida that I am filing this day in aaordance and '
in conformity with Chapter 222, Section 222.17, Florida Statutes.
1 was formarly a legal ~esident of -_~O1ttID.b1~ _ geIItucky _
(City) (State)
and I ~esided at ___80? WT1ght DY'ive ~,~,~ever 1 have changed my domiti~e
(St~eet and Number)
to an~ am and have been a bona fide reside~t of the State of Florida since --__~$~~1 day of
_ December ,~q 6~and I reside a* 110? Trinidad Ave.
. ' (Street and Number)
fORT PIERCE, SAINT lUC1E COUNTY, FLORIDA
and this statement is to be taken as my declaratio~ of citizenship, actual legal residence and domicile in the State of Horida.
(Insert here any pertinent fads, such as sate of property or business, or relinquishment of emptoyment f
at former domicife, removal of family to new domicile, purchase of home, ett.)
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Establishing residence and applying for homestead
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~ I FURTHER CERTIFY that 1 wil) comply with all other requiremenis of a leya) resident of this State.
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I FURTHER ~CERTIFY that 1 have no intention to return to my former domicile, and I intend to remain in FORT
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~IERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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5wo~n ~to and subscribed before me this 2nd day of ~BTCh ~ ~q ?0 `
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~ ROGER POITRAS ;
LERK CIRCUIT COURT Notary Public {
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By 0.C. My Commiuion expires ~
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~ (To bs ~xecuted in duplicat~ and ori~insl filed with Clerlc Grcuit Cour~, and dupliut~ with Tax Ass~stor.) ~
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