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DeClaration ot DotniCile and Citize~ship
TO THE STATE AND COUNTY TAX ASSESSOR, 2t)9009
Sl. IUCIE COUNTY, FLORIUA:
m filin this da in actordante and ~
This is my declaration of Uomicile and Citizensh~p ~n the State of Flonda that 1 a g y ~
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~n confo~mity with Chapter 222, Sectio~ 222.17, Florida Statutes. 4
I was forme~ly a legal resident of _~~~__S~~- -
~C;ty~ (State) ~
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and I resided at _ ,~7~i . However 1 have changed my domiGle
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ro and am and have been a bona fide resident of the State of Florida since _ day of
_QG ~D ~ E~ _ , 19_S?~ and I reside at ~ ~O~C /
- - - - ~ - - - -
(Street and Number)
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 former domicile, removal of family to new domicile, pu~chase of home, etc.)
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'~O'lnC'~l~tl'G ~j~c~~ J ,t ik: _ ~G.L~A'~ i
FILEO AMO RECOROE~ . }
ST. LUCIE COUMTY Fl dY'
ROCER POITRAS ~
CtERK CIRCUIT COURT c
RECORD YERIFIEO~
M~Y 10 12 ~s PM'11
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1 FURTHER CERTIFY that I will comply with all other requirements of a legal resident of 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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PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. ~
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(Name) S~.nTj- ~
rnARY - i
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R~ (Address)
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SvYOn?,b.~i~tl~~ubscribed before me this C~ day of - , 19-~•
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' t. - ;s - Notary Publ ic
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By ~ ` D.C. My Commission expires
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(To h~ o~N7~d in dupliut~ and on~inal Rl~d with Gfrk Circuh Cou~i, snd dup{iu» witl~ Tax Ass~ssor.)
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