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Declaration ot Domicile and Citizenship ~
TO THE STATE AND COUNTY TAX ASSESSOR. ~14936
Si. LUCIE ~OUNTY, FLORIDA:
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This is my decla~ation of Uomicile and Citizenship in the State of Florida that I am filing this day in ectordance and
in conformity with Chapter 222, Section 222.17, Florida Statutes.
I was formerly a legal ~esident of _ _ ~ _ _ L" ' -
(City) (State)
and 1 resided at __/c____ ~ . However 1 have changed my domitile
(Street and Number)
to and am and have been a bona fide resident of the State of Florida since C.4C~~S, _ day of
tl
- _ . 19__~~ and I ~eside at - ~z `~-~a.~~------. - -
(Street and Number)
FORT PIERCE, SAINT IUCIE COUNTY, FLORIDA
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 pertine~t facts, such as sale of property or business, or relinquishment of employment
at former domicite, removal of family to new domicile, purchase of home, etc.)
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CLER ~Ea~~iEO COUI11
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1 FURTHER CERTIFY that 1 will comply with all other requirements of a leyal residant of this State.
1 fURTHER CERTIFY that 1 have no intention to return to my former domiule, and I intend to remain in FORT
PIERCE, SAINT' LUCIE COUNTY, FLORIDA, permanenNy.
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Sworn to and subscribed before me this _ day of ~!K" , 19~1.
ROGER POITRAS - - - -
CIERK CIRCUIT COURT - Notary Public
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" By ~~3~ " .C. My Commission expires
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(To b~ ~x~cut~d in dupliut~ and oripinal fil~d witb C{trk Grcuit Courf, and dupliut~ with Tax Ass~ssor.)
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