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206163
DeCiarat~on ot Domicile and Citizenship
TO THE STATE AND COUNTY TAX ASSESSOR,
51. LUCIE COUNTY, FLORIDA:
This is my declaration of Dom~ule and Citizenship in the State of Florida that I am filing this day in accordance and
~n conformity with Chapter ?22, Section ?22.17, Florida Statutes.
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I was formeriy a legal resident of r211
(City) (State) ~
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and I resided at ` ~ ~ . _ _ _ ~ d ~ _ However 1 have changed my domicjle ~
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to and am and have been a bona fide resident of the State of Florida since _ day of
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_ ~ . 19~L' , and I reside at _ ~ ! . " - - . - -
(Sireet nd Number)
FORT PIERCE, SAINT LUCIE COUNTY, fLORIDA
and this statement is to be taken as my declaration of citizenship, actual legal resiclence 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 famiiy to new domicile, purchase of home, etc.)
Residence
Homestead 2 0 616 3
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ST~~UCIE COUNTY
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RECORD VERIf1E0
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~ 1 FURTHER CERTIFY that I will compl with all other r uirements of a I al resident of this State.
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~ I FURTHER CERTIFY that 1 have no intention to return to m mer domiule, and I intend to emain in FORT
~ PIERCE, SAINT LUCIE COUNTY, FLORIDA, permane~tly. ~ ~ ~L~~~~
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~ SwOm to a~d subx~ibed before me this ___/~0 u
day of - 19~ - -
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: ROGER POITRAS
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~ K CIRCUIT COURT Notary Public
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~ 8y ~`_h__' _ _ D.C_ My Commission expires _
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(To bs executed in duplicate sqd ori~inai ~ilsd witl~ Cl~tk Grcuit Court, and duplica» with Tax Assessor.)
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