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Declaration of Domicile and Citizenship ~
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192`79~ ;
TO THE STATE AND COUNTY TAX ASSESSOR, ~
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Sl. LUCIE COUNTY, FLORIDA:
This is my declaration of Domicile and Citize~ship in the State of Florida that I am filing this day in accordan:.e and
in conformity with Chapter 222, Section 222.17, Florida Statutes. {
I was formerly a legal resident of I±On$_ISland _ Hew YOI'~C _
~C;ty) (State) .
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and 1 resided at __~~._FiZ~#~T Street Williston P~k Flcwever I have changed my domitile
~ (Street a~d Number)
to and am and have been a bona fide resident of the State of Florida since day of
__-__~priL , 19~Q, and I ~eside ar _3? Club Drine
(Street and Number)
FORT PtERCE, SAINT LUCIE COUNTY, fLORIDA
and this statement is to be taken as my declaration ot citizenship, actual legal residence and domicile in the State of Florida. !
(Insert here any pertinent facts, such as sale of property or business, or relinquishment of employment {
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at former domicile, removal of family to new domicile, purchase of home, etc.)
Establishing residence
FILEO AND RECOROEOi
ST, ~UCIE COUNTY. FLA..
~~cor~~ ~:ER~FIE19~'196
'TO APR 30 Pa 3:25____
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I fiOaE? :•OfTFi~S
E CL~RK CIRCUIT COURT4
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i FURTHER CERTIFY that I will comply with all other requirements of a legal resident of this State. ~
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! FURTHER CERTIFY that I have no intention to return to my former domi~ile, and I intend to remain in FORT
PIERCE,~,8~l1Nt/°L~YX'ylE COUNTY, FLORIDA, permanently.
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~ ~ 30th April 70
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~ ~worn fo and sub~cribed-before me this day of . 1 • '
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~ ROGER POITRAS '
~ LERK CIR~.I#~ COURT Notary Public '
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~ By D.C. My Commission expires
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~ (i'o bs executed in dupliute and originsl filed with Clerk Grcuit Court, snd duplicat~ with Tsx Ass~s~or.)
~ 13 BDOK~L~~ PAGE.~ ~
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