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Oaciaration ot Domicile and Citisenship
2i2223
TO THE STATE ANO COUNTY TAX ASSESSOR,
51. tUC1E COUNTY, FIORiDA~
This is my declaration of Oom~ule and Citizenship in the Sta~e of Florida that ! am filing this day in accordance and
~n conformity with Chapter 22?, Section ?~2.17, Florida Statutes. ~
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I was forme~ly a legal resident of C Al4_ ~.,-fs 1?~ _ _ _ _ _ - _ - _ _ _ V q.
(Ciy) (State)
and 1 ~esided at t N ~ C K~t'-~ R~'_-!~~-- - Nowever 1 have changed my domitG~e
(St~eet and Number)
to and am and have been a bona fide ~esident of the State of Flori~li s~nce I:3.~~ _ day of
. +
~ V N F` , 19 7 I, ar,d I ~eside at ~ Z j _R/ I!L~Q~~ Y A- . ~
(Street and Number) ~
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA •
and this statement is to be taken as my declaration of citizenship, actuat legal residence and domicile ~n the State of Horida.
(Inse~~ here any pertinent facts, such as sale of property or busi~ess, or relinquishment of employment
at former domicile, removal of family to ~ew domicile, purchase of home, etc.)
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212223
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IUCIE COUMTY~~IA.
ROCER POITRAS
ClE1tK CIRCUIt CO{!RT
RECORD YERIFIEO~.~...~..
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1 FURTHER GERTIFY that I will comply with all other requirements of a legal resident of this State.
I FURTHER CERTIFY that I have no intention to ret~rn to my former domi~ile, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUN7Y, FLORIDA, permanently_ ~ `
. • • . ` /`r ~
~ tName)
. = Dia~id 8 P~nley
' ; . (Address)
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Sworn to and subxr~bed before me this _ day o~_-~ , 19
,
ROGER POITRAS - - . - . - - - ~
CIRCUIT OUltT Notary Public
J ~'~l/ /~W r~
By _ _ D.C. My Commission expi~es
(To b~ ~x~cut~d in dupliut~ and ori9lnal fil~d witl~ G~rk Circuit Court, and dupliuts witl~ Tax Aswssor.)
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