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Declaratio~ ot Domicil• and Citis~nship
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TO THE STATE AND COUNTY TAX ASSESSOR,
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51. WCIE COUNTY, FIORIDA:
This is my decla~ation of Domic+le and Citizenship in the State of Flo~id• that 1 am filiny this day in aooordance and
~n conformity with Chapter 222, Section 22?.17. Florids Statut~s.
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I was fo~ms~ly e 1e9a1 ~eside~t of
(City) (Sts»)
and 1 resided aN!
7! - - `'~~-~F - - ?~owe~er ~ ha~e char?fled my domidle
(St~eet a~d Number)
to and am a~d have been a bo~a fide ~esident of the Stats of Fiorida since _!_i~~~ ~ dey of
I +o~ ~ 19.11_, and I ~eside at fSL' ~v~~ ~71~+' ~ f.~E~
~ _ (Straet and Number)
I'tT AE~c t
FORT rlERCE„ WNT LUCIE COUNTY, RORI~A
and this atateme~t is to be taken as my declaration of citizenship, actual legal reside~ce and domicile in the State of Horida.
(Insert he~e any pertinent fads, such as sale of property or buaineu, or relinquishmer~t of employment
at former domicile, removal af family to ~ew domicile, pu?chase of home, etc.)
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LUCIE COUNTY~i~A.
ROCEti POITRAS
- CLERI~ CIRCWT OWMT
IIECORD VERIFIEO~
.lu~ 1 10 si AN'TI
210~29
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1 FURTHER C'E~tTIFY that 1 will aomply with all other nqulr~ments of a leqal residMt of this Stats.
I fURTHER CERTIFY that I have no intention to retum to my former domiGle, a~d 1 intertd to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FIORIDA, permanently.
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~ Swbi~~~tubstrib~d before me this day of . 19 •
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. : p_~ Notary Public
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.C. My Commission expires
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r, rl~piicata and ori9ieal Al~d whb Cl~c Circvif Cou~f. ~nd duplicN~ wiN~ Tax As~e~.)
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a~~192 25T7
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