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Declaration at Dt~micite and ~itisenship ~33,1
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10 THE STATE AND COUNTY TAX ASSESSOR,
~i. IUCIE COUNTY, FtORlDA
Ih~s ~s my declaral~on of Uom~c~!e and Cihzensh~p ~n the State of Flor~da that 1 am fil~ng this day in accordance and
~n co~formity w;tF~ Chapter ?22, Section ??2.17, Florida Statutes
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1 was formerly a legal ~esident of
C;ty~ (State)
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and I resided at ~C/ ~ c~~ ~/~i~/~.~ l!y~ However 1 have changed my domiCile
(Street 6nd Number)
~o and am and have been a bona fide resident of the State of Florida since oC. day of
`"~J , 19 7/ , and I reside at a ~n~ •
(Street and Numbe~)
FORT PIERCE, SAINT lUCIE COUNTY, fLORIDA
:~nd this statement is ro be taken as my dec~aration 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, rernoval of family to new domicile, purchase of home, etc.)
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~ ~ AOCER FOItR/~S
~ QIERK Ci~ It ~j .
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1 FURTHER CERiIFY that I will comply with all other requirements of a legal resident of this State. ;
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1 FURTHER CERTIFY that I have no intention to refurn to my o er domic,ile, and I intend to remain in FORT
PIERCE, SAiNT lUClE COUNTY, fLORIDA, permanently. J e SaUID .
, _ ~ (Name) ~
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~ Sworn ta anA'subscribed before me this _ day of _ 1~~--~ 19
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ROGER POITRAS
~ CLERK CIRCUIT COURT Notary Public
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BY ~-~lL_~` c- - D.C_ My Commission expi~es
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~ (To be sxecuted in duplicate and original filed with Clerk Circuit Court, and duplicste with Tax Assessor.)
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k 194 2241
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