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Lleclarstion ot Domicite and Citize~ship
TO THE STATE AND CQUNiY TAX ASSESSOR. ~SAAO~ ~
afaf
iUCIE COUNTY, FLORIDA
Th~s ~s my deClarefion ot Domi~ile and Cit~zensh~p in the Sta~e of Flonda that 1 am fil~ng this day in accordance and
~n conformiry with Chapter 222, Section 222.17, Florida Statutes.
I was formerly a legal ~esident of `~~~Y1~T~~< _ ~~~~"-j ~n`=u "
ity) (Statel
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a~d ! resided at ~<<ti ~_.~~~f -~f~Lt''~ However 1 have changed my domicriie t
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(Street a~d Number) ~
!o and am and have been a bona fide resident of the State of Florida since f~_~~~ ~-~T ~ day of ~
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_ , 19_ _ , and I reside at Z~ ~ .~-G~~ _ _ ~-'L'
(Street and Number) '
FORT PIERCE, SAINT LUCIE COUNTY, FIORIDA
and this statement is to be taken as my decla~ation of cituenship, actual legal residence and dom~cile in the State of Florida_
(Insert here any pertinent facts, such as sale of property or business, or relinquishment of empfoyment
at former domicile, removal of family to ~ew domicile, purchase of home, etc.)
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~ - ~ r:_ , < < L r, ~-~i ~ ST
ltiC1E C~UMTr~IA.
• . ~ ` ROCER Pa~TRAB
CLER~ CiRCU1T ~ R
~ECORO YER!fIEO~~~~
~ S ~Z 23 ~N'l~
~ 213309
I FURTHER CERTIFY that 1 wilt comply with all other ~requirements of a legal resident of this State.
~ 4 I FURTHER CERTIFY that I have no intention to return to my former domiGte, and t intend to remair ~n FORT
~ aiERCF, SAINT lUC1E COUNTY, FlOi21DA, permanently.
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~ Sworn to and subscnbed before me th~s _ _ day of _ 19.1~.
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~ ROGER POITRAS - - - _ - - -
~ CLERK CIRCUIT COUR~ Netary Pub!+c
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~ By _ !~L''r~`~'~~ - _ D.C. My Commission expires
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(To b~ ~x~eut~d in duplieat~ and ori~inal fil~d with Cl~e~c Greuit Court, and duplisat~ with Tax Ass~ssor.)
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