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V
Declaration ot Domicile and Citisenship
TO THE STATE ANO COUNTY TAX ASSESSOR,
Sl. LUCIE COUNTY, FLORIDA:
This is my declaration of Domicile and Citizensh~p in the State of Florida that 1 am filing this day in accordance and
~n conformity with Chapter 222, Section 222.17, Florida Statutes.
1 was formerly a legal resident of L L~_ A~l A N~
(City) (State)
and I resided at ~ l Y_ N_ C_A_ S~ F~ /T O A D However I have changed my domiti~e
(Street and Number)
to and am and have been a bona fide resident of the State of Florida since _ ___~_1!!~__ _ day of
S ~-pT ~ ~ ~ ~1 - - - - - 19-1 V and 1 reside at ~ ~
3_1~ ~ / N,Do ~ /q _~T' S
(Street and Number)
FORT PiERCE, SAINT LUCIE COUNTY, RORIDA
and this statement is to be taken as my declaration of citizenship, adual legal residence and domicile in the State of Florida.
(Insert here any pertinent facts, such as sale of property or bus+ness, or relinquishment of employment
at former domicile, removal of family to new domicite, purchase of home, etc.)
Sqt ~ eF ARvP~R~~
REAaou9L oF Farn~~y -r'~• new d~~/cl~~
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~ 1 FURTHER CERTIFY that I will comply with all othar requirements of a(eyal resident of this State.
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I FURTHER CERTIFY that 1 have no intention to return to my former domicjle, and I intend to remain in FORT
~ PiER*~ ~T~d1J~JE COUNTY, FLORIDA, permanently.
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~ Sworn to and subsc~ibed before me this - day of - _ , 19 .
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~ ROGER POITRAS _ ~ _
~ K CiRCU1T GOURT Notary Public
~ a <_..Gr~
~ -Zca~e-c-lC-~'
} - _ D.C. My Commission expires
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~ (To b~ ~x~cuhd in dupliut~ and ori~lnal fil~d wifh CI~?k Circuit Court, •nd dupliut~ with Tax Ass~ssor.)
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