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Declaration ot DomiCile and Citizenship
TO THE JTATE AND C^vUf`TY TAX AS~ES~CR, ~~~ij~' ~O
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~i LUCIE COUNTY, FIORIDA
Th~s +s ~»y declarat~on of Do~n~c~ie a~~d C:~t+zensh~p ~n t>~.~ STale t~f Fiorida that i am t~t~ng th~s day ~n accordance and
~n coriformity w~!h Charter 222. ~ect~on 2?2.17, Florida ~I6~JiC}.
i was formeriy a legal resident of u. if~.7j
iCity:~ (State)
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and 1 resided at~ r~:J ~~i - 7"~ ~ However i have changed my domi~ile
(Street anci tRamre:l
!o and am and have been a bona fide residenr of the State oi F:a-:da s;nce day ot
[til<< • Lf~.'r
l/; ~0~~~/C . 19 an~ 1 res~de ar rl y- 1'i'X ~'~Q- ~~Jd1k~ ~c~. ~j' _~~v1.- :
(5treet and Nu~r~ r) ~
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FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA -
and this statement is !o he ~ak2rs :~~y dC,~arat~on of c:ri~p~sht~, actua~ !ega! ~es~c3ence and domicile ~n the State of Florida.
(Insert here a~~y pertinerc jads, su:h as sa?e of ~:~~erry or bus~ness; or -eiinquishment of employment
at former dorn~c~ie, rem~va! ~f family to new dom~ciie, purchase cf home, etc.)
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~ I FllR.T!-!ER CEP.TlFY lhai ! w~{I comply with all other requirements of a 1~ga1 resident of th6s State.
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x ! FiJRTtiER CER i~FY that i have no intention ro return to my ro~~er domiC;ie, and I intend to rema;n ~re FCRT
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PIERCE, SAWT l~lCIE CDUNTY. ~LORI~A, permar.entl;
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; Sworn SQ'a~d subscr;bed i;efore me rh~s L~ daq of L~ i9_I~
RUGER POITRAS
Ct~RK CfRCUiT COl:dT Nofary Pubi~c
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p ` ~ ~ C M• Comrniss~on ex ires
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~ (To be exewted in du~licair. a::~ ssngi+ta4 ~!ed vrefih ~l~rk Citcuit Court, and dupliuts with Tsx Ass~swr.j
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