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Declsratian ot Oorrl~il~ and Gitizenshlp
TO THE STATE AND COUNTY TAX A$SESSC)R.
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Sl LUCIE COUNTY, FlORIOA
This ~s my dec!arat~on of Dom~c~le and Citizensh~p in !he State of Florida that 1 am fi~ing this day ~n accordance and
+n conformity with Chapter 2:2, Section ?22.17 Florida Sta'~tes. _
1 was formerly a legal resident of ~O k~I~ t" 1YQ-~~~ 0~~~'
~ (C~ty~ (State)
~nd 1 resided at i'[~ ~~~~1~ ~r V C • However t have changed my domi~ile
(Street and iVumber)
~o and am and have been a bona fide resident of the State of Florida since ~ Lt ~~l Q ~p day of
, 19_ and I reside at ~{p n S ~.1-~-~Y r
(Street an~Number)
FORT PIERCE, SAINT LUCIE COUNTY, FtORIDA
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, purchase of home, etc.) ~ ~
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~1''n ~ Q ~ J ~ ~ ~ ~ ~ FILEO AN~ RECOR~~
~ re.~ ST.I~UCiE~COtiNTY LA. ~
OCE POITRAS
~ CIERK C~RCUIT COUItT ~ :
~ ~Q 1 1V ~Q ~ ~ AECORD YERIFIED~
b~ Auc I I 12 26 PM'1 I
~ ~~t ca~ ~ 1~
~ 22~65 -
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~ I FURTHER CERTIFIf that I will comply with all other requirements of a legal resideni of this State.
~ I FURTHER CERTIFY that I have no intention to return to my former domiGle, and 1 intend to remain in fORT ;
4
PIERCE, SAINT LUCIE COUNTY, FIORIDA, permanently. 3
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~ - (Name) ~s~ MP `t
~ ~1~~~ ~2~~__s~4`1°~~
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~ Sworn to and subscrieed before me this ____~1-__ _ day of _c ~~~c~ 19_~ #
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~ ROGER POITRAS: r ~ - - - - - - -
~ CIERK CIRCUIT_COURT _ , Notary Public
~ By - D.C_ My Commission expires
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(To bs exacuhd in•dupUesN and oriyinal filed with Cl~rk Circuit Court, snd duplis,~ts with Tax Ass~ssor.)
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~ ~ 194 188~
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