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_ O~1uat1dfl 01 oOlrfi~ll~ a111! CitlsMShip
TA THE STATE AND COUNTY TAX ASSESSOR. • i~4H1~
ST. LtK1E tOl1NTY, fIORIDA:
Thjs i~ my d~ciaration of Domicil~ ~~d Citisi-nship ln th~ St~t~ of Florida th~t 1 am Hiiiq this day tn aaoordar~a a~d.
in conformity with Chapt~ ~~'2, S~ttion 2?4.17, Florida ShtuNs. .
I wa: formKly a Ipel resid~nt of l~"~s~'~" ~4 ~
(City (Sta1~)
snd 1. rosidsd at 'Q- ~ T/ , I~~ ' . Howwu 1 haw ch~~p~d my domkiN
. (Stn~t and Number)
b and am and have bee~ a bona Hde tesid~nt of ihs Stah of Florida sino~ l3 day of
. , 19~, and 1 rosids N ~7 ~ v 4/` ~ rZ
(5t~t ~od NumbK) ~ .
~ORT ~IERCE, SAINT tUC~ COUNTY, ROR~A
and this statemsnt is to bs taken as my dsdsration of c~ti~sr~ship, aduai le~l residsnoa snd domicil~ in th~ State of Horida.
{Insen here any pertineM facts, such as sale of propert~r os bu:in~ss, or relinqui:hmsht of employm~m
at ~ormer domkile, ronwval of fsmily to new don~icil~, purchase of iwrne. ~tc.~
~I'--~"_ ~
, ~Fl~j"AMp RECARp6Q~~
' ~ . ~ ST. LUClE' ~OUN1Y~ F'L,~~
RECORD V~RIFIE~°
-197481~ .
70 l~ ~ I. ~M 10 ~~I7
_
ROGER POITRA`$ ~
~ _ . CL.ERK CIRCU11~ COURi~
~
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1 FURTHER t6RTiFY ffiat 1 will aompfy wHh ~II oth~r r~qui~fs of a Ipal resideM of this Stat~.
I FURTHER CERTIFY that I have no intention to retum ~o my former domiCile, ~nd I intend .to remsin in FORT
PIERCE. SAiNT LUCIE COUNTY, FLORIDA, petmanently.
.
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S~~` .:~~pr'b~! bsfore mt this "Z day of 19~~
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