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Decla~ation ot Domicll• and Citizanship
TO THE STATE AND COUPITY TAX ASSESSOR,
Sl. IUCIE ~OUNTY, FIORIDA:
This is my declaration of Domicile and ~itizenship in the State of Florida that 1 am filin~ this day in acaordance and
in conformity with Chapter 222, Section 222.17, Florida Statutes.
I was formerly a legal ~esident of ~est Land Michigan _
(Ciy) (State)
and I resided at _~005 Ot88A0 However I have chanqad my domitile
(Street and Number)
ro and am and have been a bona fide resident of the Staro of Flwida sinee let day of
1502 Ave B
July , t969 , and I roside at ~Z~~C~~Z~~~t
(Street and Number)
fORT MERCE, SAIN? LUCIE COUNTY, RORIDA
and this statemen* is to be taken as my declaration of citizenship, actual legal residen~ and domicile in fhe State of Horida.
(Insert here any pertinent facts, such as sale of property or busineu, or relinquishment of employment
at former domicite, removal of family to new domicile, purchase of home, etc.) .
Establishing reeidence and applying for homesteed
FILEO AND RECORDEO". r
5Y. LUCIE COUNTY. FLA. ~
_ RE:C~JRO VERIFIED
19~663
~ 'T0 MAR 3I PN 1: 0 ~
!
C ~OGER ~ OITRAS
~ CLERK CIRCUIT COURT'
1 FURTHER CERTIFY that I will aompty with all other requirements of a layal reside~t of this State.
I FURTHER CERTIFY that I have no intention to retum to my former domitjle, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FIORIDA, permanently.
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~ s,v,Qpin•10 and s~bscribed before me this ~lgt day of l[areh , ~9~,
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~ ROGER POiTRAS "
~ CIRCUIT OURT Notary Public .
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8y D.C. My Commission expirea
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~ (To b~ uacvhd in dupliub and aiainsl fil~d with CiNic Ciraiit Cou~f, and duplicat~ witb Tax AtMaor.)
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