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Decla~ation at Domicile ~nd ~Citize~ahlp ~
TU iHE STATE ANO COUNTY TAX ASSESSOR. ~1~94
51. lUC1E COUNTY, F~ORIDA
ihis ~s my declaralion of Qomicile and Cit~zensh~p in !he State of Florida that 1 am til~ng this day in accordance and
~n conformi~y with Chapter 222, Sectio~ 2?2.17, florida Statutes
• ~-~G~~~Z~7/! -t~~"4v~
1 was forn?erly a legal resident of _
. ' f' ~~-~~~~~+v (City) (State)
and I resided at / _ Howeve~ 1 have changed my domiG~e
(St~cet and Number) ~
ro and am and have been a bona fide resident of the State of Florida since day of
, 19_ , snd I reside at l~'n~$ ~V,~__~___-__`
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, FLOltIDA ~~-~u -~~l '
and this statement is to be taken as my declaration of citizensh~p, actual legal reside~~ce 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, purthase of home, etc.)
)
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ST. LitCIE ~CYNtT ~
R~;ER POiTUS
Ctf1l[ CIRCMT ~c~
RE~OIt~ Y£MftED~
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i fURTHER CERTIFY that 1 will comply with all other requirements of a IegaS resident of this State.
I FURTNER CERT~FY that I have no intention to ~eturn to my forr:~~er domic,ile, and I intend to remain in FORT 1
;
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~ PIERCE, SAfNT LUCIE COUNTY, FLORIDA, permanently. _ ~ -
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sG~~ ~C~--~~G~-~-!
~ ; . , i - ~Name) - -
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~ $worn to and subscribed before me ihis _ day ot ~Gd~ _ _ 19 =
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~ ROGER POITRAS - ;
~K CIRCUIT COURT _ Nottry Public ~
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By ~ ~ _ D.C_ My Commission expires ~
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~ (To be executed in dvplicste snd originsl ~iled with Clerk Grcuit Court, an~ duplicate with Tsx Assessor.)
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