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Declaratio~ ot ~omicile and Citisenship ~
TO THE STATE AND COUNTY TAX ASSESSOR. 2146~8
Sl. ~LUCIE COUNTY, FLORI~A:
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This is my declaration of Domicile a~d Citizenship in the State of Florida that I am filing this day in accordance and ~
in conformity with Chapter 222, Settion 222.17, Florida Statutes.
I was formerly a legal resident of QQ~ 1xLLY__~~---_ f:
(Ciy) (State)
and 1 resided at /~~4!-~ - a~ . However 1 have changed my domic.ile
(Street and Number)
ro and am a~d have been a bo~a fide resident of the State of Florida since ~D Y_ £~rt bP_+~ _ day of
l
- - _ - 1911 and I reside at ~Q.~ LLZ~ ~ •
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, KQRIDA
and this statement is to be taken as my declaration 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, removal of family to new domicile, purchase of home, etc.)
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J~an ~ F£ ff,~Q(~ rSo n/
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FI~EO AM~ RECORQEO
ST. LUCIE CQUMTr FIA.
ROGER POITRAS
CIERK CtRCU1T COi1Rt
~ RECORO VERIFIEO
AIIC Z6 IO ~ ~M'T~
~ 214so8
E
!~llRTH~~t ~~TlFY tha! ! w~!! c~±ply with ot~r r~qulr~sn~~t~ Qf ~ r~:dent Qf thi~ ~t~te.
I FURTHER CERTIFY that 1 have no intention to return to my former domiule, and I intend to remain in FORT
PIERCE, SAlNT LUCIE COUNTY, FLORI~A, permanently.
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(Na me)
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- ~fjd svbxribed before me this day of , 19~
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R ,K'It?RAS
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''C~K•~tkCU1T COURT , Notary Pubtic
k By ~ D.C. My Commission expires
(To bs ~x~eut~d in dupliut~ and ori~insl fil~d with C{~ek Cireuit Court, and dupliwt~ wiTh Tax Ass~sw?.)
a ~ ~,~95 ~acE 299
No. 13
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