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Declaratio~ ot Domicile and Citlze~ship
TO THE STATE ANO COUNTY TAX ASSESSOR. 214120
51 lUC1E COUNTY, FIORIDA:
This is my declaration of Dom~c~le and Citize~sh~p in the State of Florida that 1 am filing this day in accordance and ~
~n conformity with Chapter 222, Scction 22?.17, F;~:ida Statutes.
1 was for~erly a legal resident of ~L~Z l~.~ . -
~ • ~ (State)
and I ~esided at .7U~I /c~~ - _ . However I have changed my domitile
(Street and Number)
k
to and am and have been a bo~a fide resident of the State of Florida since ~ _ day of j
1
/ ~ s~G- ~
_ , 19~/. and 1 reside at - _ - ' - _
~ ~ (Street and Numbe~) ~
FORT PIERCE, SAINT LUCIE C04NTY, fIORIDA ~
and this statement is to be taken as my declaration of citizenship, actual Iegal residence and domicile in the State of Florida. '
(Inse~t here any pe~ti~ent facts, such as sale of property or business, or ~elinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
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' I FURTHER CERTIFY that 1 will comply with all other requirements of a legal resident of this 5tate.
! FURTHER CERTIFY that I have no intention to return to my former domicjle, and I intend to remain in FORT
PlERCE„SAFNT LUCIE COUNTY, FIORIDA, permanently. CHARI,ENE WITT
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~ Swom to and subxribed before me this day of , 19~_.
~
~ ROGER POITRAS - - -
~ CtRCUIT COURT Notary Public
` ~
~ By - D.C_ My Commission expires
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(To b~ ~x~cut~d in ~uplicat~ and oripinsl filed with CIKk Gnvit Court, •nd dupliutt with Tax Ass~ssor.)
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