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Declaration ot Do~nicile and Citisenshfp
TO THE STATE AND COUNTY TAX ASSESSOR, ~r~t~323
51. LUCIE COUNTY, FIORI~A:
Th~s is my declaration of Domicile and Citizenship in the State of Florida thst I am filing this day in accordance and
in confo~mity with Chapler 222, Section 22?.17, Floride Statutes.
I was formerly a legal resident of ~ _ U~~~
(City) (Sta»)
and I rosided at __.~t' Gt-~A-- ~ However I have chanflad my domitile
(St~eet and Numbe~)
to and am a~d have been a bona fide resident of the Stste of Florida since day of
C~~1~~ 192 and 1 reside st ~f
~ LtQ2c. u~ 3~~~7
T7 K~ Fy ~~O~,Y ~t Num ~a (i~11c~0~u
FORT rIERCE, SAINT LUCIE COUNTY, RORIDA 4' a~/t/~/`
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Florida.
(Inse~t here any pertinent facts, such as sale of property or busineu, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
FIIED ANO IIECORQEO
~T.IUCtE COUNTY fLA.
ROGER t01TRAS
RECORD VER~F
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2G4323
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~ I FURTHER GERTIFlf fhat I will oomply with all other requirements of a le~al ~esidant of this Stete.
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~ 1 FURTHER CERTIFY that I have no intention to return to my former domicjle, and I intend to remain in FORT
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~ PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently_
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~ ~ (Name)
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;ti.~~;br~~•~nd subscribed before me this ` day of 19~
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8y~(•~'• ' D.C. My Commissicn expires
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~ ~(rte~Y~•~nwted in duplluh and ori~inal filsd with Cf~elt CircuN Courf, and duplica~ with Tax AswMOr.)
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