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Declaration ot Domicile and Citizenship 21516
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TO THE STATE AND COUNTY TAX ASSESSOR,
Sl. WCIE COUNTY, FLORIDA:
O11Y' W e ~'e ~
This is l4~ declaration of ~omicile and Citizenship i~ the St;,te of Florida that IC~li filing this day in accordance arxl ~
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~n conformity with Chapter 222, Section 222.17, .Florida Statutes. ;
W e were
]t7p~lOC~Eormerly a legal resident~f ~~lbi~~')I _ _ _ _ C~CL1C11L`______ .
(C~tyy (State)
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~re our ~
andZresided at _ V~Q~ RCdd~_R4~ _ _ _ _ Howevef khave changed ~domitile (
(Street and Number)
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to and a~ and have been Y bona fide reside?t~f the State of Florida since i~th _ day of ~
August ~9?i , and I~reside at 30~Block A. S. Bo111t8 D~`ive, ~oiia~c out ~
at St. L1iCie , a Condominium, (Street and Number) ~
X~~f~~ SAINT LUCIE COUNTY, FLORIDA {
our `
and this statement is to be taken as df~ declaration of titizenship, actual le~al residence and domicile in ihe State of Flarida. +
(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.)
Purchase oi Lat 30, Block A of Holiday Out and removal of family to
Florida
215163 ;
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f~~EO ~wo aECOR~~o ~
` ST. aOCER P01TaAi`A.
CIERK CIRCUIT COUI~t ;
AECOaO VER~f1ED ~
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We we •
~I FURTHER CERTIFY that ~ will mmply with al) other requirements of a legal resident c~f this Sfate.
We a?e o we
H011d8y~VUTT~F~~E(~T~~t~~t ~ have no intention to return to f ine omiCile n inten ~ o remain in 7~R~ .
xAf~ SAINT LUCIE COUNTY, fIORIDA, permanently. ~
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1
(Name) ~
Lot 30. Block A. S. Bonita Drive, ~
Holida Out at St. Lucie.
~ ~ (A dress ~
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Swom to and subscribed before me this ____3ra day of _______S~e=Y~b~~±`~_T..~ .,;-~~;~q~__ ~
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. ~ L : o : t%,~, 7~'~ _ ~ ~
ROGER POITRAS - t~-`-~~,l~ ' ~ ~ ~ _ _ f
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CLERK GIRCUIT COURT - Notary ubtic:•. , i:
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g . _ D.C. My Commission expires ~ ,
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(To bs ~xecuted in duplicate and origi~al ~Isd with CI~?k Circuit Court, and duplicat~ with Tsx I?sseswr.) ~
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