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DeClaratio~ ot Domicile ~nd Citizenship
TO TtiE STATE ANO COUNTY TAX ASSESSOR,
~~37~'/ ~
Sl. LUCIE COIINTY, FLORI~A:
~
This ~s my declaration of ~omicile and Citizensh~p in the Stare of Floriaa that i arr. fili~~g this day in accordance and
~n conformity with Chapter 222, Section 222.17, Florida Statutes.
I was formerly a legal rasident of ~/r(f. s l~~-~[.~1~
9 ~
(C;ty) (State)
and 1 resided at 9 ~K ~ N L Hov~rever 1 have changed my domi:,ile
(Street and Number)
to and am a~d h~ve been a bona fide resident of the State af Florid~ since day of
. Q' j
. . 14_./~ , and I reside at Q ~ 7 / ~j~~~- _ `r ~i~Cr -
~ - (Street a~d ~lumber)
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
and this statement is to be taken as my declarahon of citizenship, actual legal residence and domicile in the State of Florida.
(Insert here any pertinent facts, such as sale of p~ope~ty or business, or relinquishment of employment
at former domicile, ~emoval of family to new domicile, purchase of home, etc.)
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fIlEO ~!10 RECORD ~
sT. ~uc~c couwTr f~~
Iloce~ Po~TS~s S~'
CIERK C+RCUIT ~Q~I~fi m('~1
REEORD YER~FtE9~~~.~ U
A~ I 2 1 04 ~N' ~ I
213'7~'~
I FURTHER CERTIFY ihat I will comply with a{I other requirements of a legal resident of this State.
I FURTNER CERTIFY that 1 have no intention to return to my former domic,ile, and I intend to remain in FORi
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
. . .iST CE FI:Y.
. ~ _ _ _ _ ~
. ;
~ . (Name)
8p7 ~_~xas ~ourt, Fort Pierce
~ (Address)
r , ~ ' h ~fl ~"'-"_c c " lj
Sworn to end subscribed before me this _ l°` _ _ day of _ _ _ . ~ _ _ 19
ROGER POITRAS _
CIERK CIRCUIT COURT Notary Public
8Y - ~~-~4u~_ _ ~ . ~IL L 1 c ~«~-~.C. My Commission expires
(To be execut~d in duplicste and oriQinal ~ilsd wilh Cl~rlc Grcuit Court, snd dupliut~ with Tsx Ass~ssor.) ~
~ 6,,~? i94 2016 ~
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