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Declaration of Domicile a~d Citizenshfp
TO THE 5TATE AND COUNTY TAX ASSESSOR. ~ r~~
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Sl. LUCIE COUNTY, FLORIOA
This ~s my declaration of Qomicile and Citizenship in the State of Florida that 1 am fil~ng this day in acco~dance and
;n conformity with Chapter 222. Section 2~2.17, Florida Statutes.
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I was fo~merly a legal resident of ~ ;
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~l 7 __-~-sL~ .-E' Q' l Nowever I have changed my domi~ile ;
and I resided at . -
(Street and Number) ~
!o and am and have been a bona fide ~esident of the State of Florida since 5 - day of
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, ~y-y- , 19_~~ , and 1 reside at ~ ~ ~ ~C.~t~--
(St eet and Number)
FORT PIERCE, SAINT LUCIE COUNTY, PLORIDA `
and this statement is to be taken as my declaration of c?tizenship, 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
at former domicile, removal of family to new domicile, purchase of home, etc.)
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FILED 4NC RECORDEO ~
ST. IUCIE COUMTY f~A. ~
ROCER PO?TRAS ~
CIERK C~r:CWT CO RT
RECQRD V~~!F~ED
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~ 1 FURTHER CERTIfY that 1 will comply with all other requirements of a legal resident af this State. ~
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I FURTHER CERTIFY that I have no intention to return to my former domi~ile, and I intend to remain in FORT ~
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PitRCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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~ {Name)
~ Tf'odc.~rc~E ~ ~~S5fLL_ .
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~{Y~. - 1 ~ C_~~._ ~ . _
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r~ • ~ (Address)
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~ . : _ • ! day of - . Ef~«rl'~~~ 19 - -
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. Sworn tQ~an~ subscr;bed before me this
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~ RO~i~ POITRAS / - - - - - _ - -
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~ `..~F C~iRKlIRCU j COURT ~ Notary Public
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g ~ ~ < ~c %4i ~ D.C.' My Commission exp~res
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~ (To be ~xecut~d in duplicats and ori~inal filed with Cl~rk Circuif Cou~f, and dupliut~ with Tax Assessor.)
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