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Declaration ot Domicife and Citisenship
TO THE STATE AND COUNTY TAX ASSESSOR,
53. lUC1E COUNTY, FLORIDA ~1~'~10
Th~s ~s my detlarat~on ot ~ornicile and Citizensh~p in the State of Florida that I am fil~~g this day in accordance and
~n co~fo?mity wi~h Chapter ?22, Section 222.17, Fl~rida Statutes.-
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I was formerly a legal res~dent of
(Ciy) (State)
and I resided at ~ j~~-~'`~ _ J~"_ However I have changed my domi~ile
(Street and Number)
ro and am and have been a bona fide resident of the State of Florida since _ day of
, 19._1~ , and I reside at / , -
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, FtORIDA
a~d th~s statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Florida.
(Inserr here any pe~tinent 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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FItED AMD RECOROt~
ST. ~uCIE COUNTY FlA_ ~
ROGER POITRAS .1' =
CLfR!( CIRCUIT COURT C ~
RECORD YER~FIEO
Auc 11 ~Q li aN'7 ~
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I FURTHER CERTIFI( that I will comply with all other requirements of a legal resident of ihis State.
1 FURTHER CERTIFY that I have no intention to return to my former d~mic,ile, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FIORIDA, permanently.
_ G'~-'~'`-c'L_-~1 ' / 3
~ (Name) Vc' ~1i ~ S 1 e R.
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c~th-t~o ~,~a I
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Address) ~ ~ ~
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~ Sworn ~fodnd,iybscribed before me this _ _ day of _ _ ~C c~Fc~___ 19.~~
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~ ~ RO~iER ~O~S _ - - _ - - -
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BY ~IGLi;/~•C. My Comm~ssion expires
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~ (To b~ ~x~cut~d in duplic~t~ and ori~i~al fil~d with CiKk Circuit Court, and dupliu~~ wiih Tax Ass~ssor.)
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