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Declaration ot Domicile and Cittzensh~p
TO THE STATE AND COUNTY TAX ASSESSOR, !
51. IUCiE COUNTY, FLORIDA:
This is my decfaration of Domicile and Citize~ship in the State of Florida tltiat I am filing this day in accordance and
~n conformity with Chapter 222, Section 222.17, Flo~ida Statutes.
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1 was formerly a legal resident of - f~Z~T~~t[ `u -t/~v C~-I'+Y3?-'yL
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(City) (State)
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and 1 resided at _ ~4'' __~~_._°~_T- S! . However I havechanged my domiGGle ~
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(Street and Number)
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to and am and have been a bona fide resident of the State of Florida since 4"`` ~ ~ 9~d da of i
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and I reside at / ~ `~'L!`-~~`"t~ `
- - - - - - 19-- - -Q__--- -
(Street and Numbe~) ;
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FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
and this statement is to be taken as my declaration of 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
at forme~ domicile, removal of family to new damicile, purchase of home, etc.) ~
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STLLUCIE COUNTY FLA ~
iiOCE~ POITRAS
CLERK CIRCUIT COURT
RECORD VER~f1E0~.-
fEe I7 I! 02 pM'11 ~
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~ I FURTHER CERTIFY that I will comply witfi atl other requirements of a legal resident of this~ State.
~ I 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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:~woNl~to and subscribed before me this day of , 19~~ F
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~ R ER POITRAS _ _
K CIRCUIT OURT Notary Public ~
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S ~ 1`'~'~=_ d___ J D.C. My Commission expires - (
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~ (To b~ ~x~cuted io duplicate and ori~inal ~iled with Cl~rk Clrcuit Couef, and dupliut~ witl~ Tax A:s~ssor.)
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