HomeMy WebLinkAbout0259 Deciaratio~ ot Domicil• a~d Citise~ship
TO THE STATE AND COUNTY TAX ASSESSOR,
51. LUCIE COUNTY, FIORIDA: .
This is my decla~ation of Uomicile and Citisenship in the State of Flo~ida that 1 am filin~ this day in aaoordance a~d
in conformity with Chapter 22?, Section 222.17, Florida Statutes.
1 was tormerly a legal ~esident of -~Nl~~ ~Msa -
K~tY) (State)
and I resided at ~a Howevet 1 have cfianged my domicjle ~
, (St~eet and Number)
to a~d am and have been a'bona fide resident of the State of Florida since ~ day of
~_°~!r . 19 and I reside at ~~P~ 11TT ~pi ~6 BU~6o~r~ Dt
(Street and Number)
PORT PIERCE, SA{NT LUCIE COUNTY, RORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the Staro of Horida.
(Insert here any pertinent fads, such as sale of property or business, or ~elinquishment of employme~t
at former domicile, removal of family to new domicile, purchase of home, etc.)
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_ . ~QCER PQItR~~ '
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1 FURTHER CE~tTIFY ihat 1 will oomply with all other requirements of a(a~al resident of this State.
`~.,ti_I:~URT,HER CERTIFY that I have no intention to retum to my former domi4le, and I inter+d to remain in FORT
, '
PlEflGf,- $A~,~1dC.~`~COUNTY, FLORIDA, permanently.
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" . 3 y ` j 4 . T' ~ _ ~ (Name)
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~ Sworn to and subscribed before me this 2~ day of ~d~er , 19 ~
ROGER POITRAS
CtRCUR COURT Notary Public
ey ~d~~f 0.C. My Commission expires
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~ Ro 1~ ~x~evl~d in duplie~t~ and ori~inal Rl~d whl+ C1KIc Grarit Couet, and ~plieatr wiN~ Tax Asat~or.)
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