HomeMy WebLinkAbout1627 De~:laration ot Dom~cile and Citize~ship
TO TNE STATE Ai~D COUNTY TAX ASSESSOR, _
213431
51. WCIE COUNTY, FLORIDA
This ~s my declaration of Dom~ule and Cit~zensh~p in the Sta~e of Florida that I am filing this day in accordance and
~n confo~mity with Chapter ?22, Section 222.17, Florida Statutes.
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1 was formerly a legat ~esident of ~/~f_~f1//`~//~ <--/`~`'s`-r--_ ~
(C;ty) (State)
~
and I resided at ~~l ~O!~A~e - y~ - However 1 have changed my domiG~t
(Street and Number) ~
fo and am and have been a bona fide resident of the State of Florida since ~ day af ~
. :
, 19_ , and I reside at ~f ~9 ~.l ~ ~G
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
and th~; statement ~s to be taken as my decl~ration of citizenship, actual legal residence and domicile in the State of Florida.
(Insert here any pertinent Fa;ts, such as sale of property or business, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
~ ~ c~~ e 1~ . I~cL j'C ~ ~ - rac.{~e_ 9
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~o ~ e ~ ~ I~ a ~ P r - ~ r a ~l e /
FILEO sND liECQROE~
ST.IUCIE COUMIT FLA. n
ROCER POITRAS
I REC0~0 YEP.RF1Ep COU~
i Auc 9 2 so PM' 1 I
i
21~431
I FURTHER CERTIFY that 1 wil) comply with all other requirements of a lega! resident of ihis State.
I FURTHER CERTiFY that I have no intentio~ to return to my former domi~ile, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, perrranently.
~ - - le~- ~
~ (Name)
~ _
~ ~ - -~6~ - -
~ (Address)
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~ Swom to and~wbscribed before me this day of , 19~
~ '•l. ~ '+L'• _
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~ . ~O¢ER rORRA3 - -
~ ~CLERK CIRCOI~;EOURT Notary Public
~
~
gy _ ~ .C_ My Commission expires _
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~ (To be executed in dvplicate snd original ~iled with Clerk Circuit Court, and duplicate with Tax Assessor.)
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~~UK 194 1626
N~. 13
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