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Declaration ot DomiCile and Citizenship
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TO THE STATE AND COUNTY TAX ASSESSOR,
Sl. LUCIE COUNTY. FLORIDA:
This is my declaration of Domicile and Citizenship in the State of Florida that I am filing this day in actordance and
conformity with Chapter 222, Section 222.17. Florida Statutes.
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I was fotmerly a legal resident of
. (C~~y) (State)
and I resided ar'~~'~~~ t/ . However 1 have changed my domic,ile
(Street and Number) ~
to and am and have been a bona fide ~esident of the State of Florida since day of
~h~ I resid at 6 '`'~.G ~~i
19~, and e
. (Street and Number)
FORT PIERCE, SAlNY lUC1E COUNTY, fLORIDA .
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicite in the State of Florida.
(I~seri-~ere-any pettinent fects, such as sale of properry or business, or reiinquishme~t of employment
at former domicile, removal of family to naw domicile, purchase of home, etc.)
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~15466 •
FILED RM~ RECOROEO ~
S7.lUCiE COUMTY FIA.
FtOCER PO~jaAS
~ CIERx C1~tCU1T COURT
RECORO ~cK~F1E0 ,
S~ 13 10 ~s AM'11
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1 FURTHER CERTIFY that I will comply with al) other requirements of a legal resident of this State.
t FURTHER CERTIFY that I have no intention to return to my former domic.ile, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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' (Name) f
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, (Address)
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Swor~ ~ro and subscribed before me this day of , 19~. -
~
ROGER POITRAS
~LERK CIRCUI COURT Notary Public
By "~4 ~ 0.C. My Gommission expires ;
(?o b~ oxeculed in dupliut~ and ori~i7~a1 filed with Cl~rk Gircuit Court, and duplicat~ with Tax Assesso~.)
aooK 195 PAGE 1523
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