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Deciaration ot Domicite and Citizenship ~
TO THE STATE AND COUNTY TAX ASSESSOR, '
215402 '
Sl, IUCIE COUNTY, FIORIDA:
This is,my declaration of Oomicile and Citizenship in the State of Florida that 1 am filing this day in accordante a~d I~ ,
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~n conformity with Chapter 222, Section 222.17, Florida Statutes.
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I was formerly a legal resident of ~.~.~~s_.L C
(City) (State)
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~ However 1 have cha ed m domitile j
and 1 resided at ~i?l~.rc r_~ - ~9 Y ~
(Street and Number) '
ro and am and have been a bona fide resident of the State of Florida since day of
, 1911 , and I reside at ~!~`Q-LU~'. s~ C''
(Stree~~ber~ / ~-y7
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FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
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and this statement is to be taken as my declaration of citizenship, actual legai 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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l C~ , , e , ~c ~ ~r /'7,
Lr N i~ S ~ e /7~ /l ~?.~UCIE CO~M1Y fL1?.
ROGER PO~jRAs
V / ' Clf RK CIRCUIt CO~i~(,C.G~
J e~ i t~ji r, ~ /~j~i RFCORO ~ERIf 1E0.+++'~"~
~ ~p 11 ~i AN'T 1
215402 ~
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I FURTHER CERTtFY that I will comply with al) other requirements of a legal resident of this State.
I FURTHER CERTIFY that I have no intention to return to my former domiCi~e, and I intend to remain in FORT
P,~2CE, SAINT LUCIE COUNTY, FLORIDA, permanentty. ~;t
S~a?N ~ame)~/te iJ~1o f F
/ ~ , ~-e,~ t~"~.(.t~-E ~ •
~ Address)
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Sworn to.a~}d, scribed before me this l~ day of ~ . 19-~1-•
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ROrj~t ~~~UtAS ~
GLEit~C ~l~CUIT COUQf~"~,~ Notary Public
~y ~,t`r ~ D.C. My Commission expires
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(To be ozb~ •ih duplicate .and oripi~?al filed with Clerk Circuit Couvf, snd duplicate with Tax Assessor.)
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