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Declaration ot Domicile and Citizenship
TO TFiE STATE AND COUNTY TAX ASSESSOR, ~
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Sl. WCIE COUNTY, FIORIDA:
This ~s my declarat~on of Qom~cile and Citizensh~p in the State of Florida that 1 am filing this day in accordance and
~n conformity w~th Chapter 222, Section 222.17, Fiorida Statutes.
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I was formerly a legal reside~t of 1~~~~ ~
~C~~~ (State)
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and 1 resided at .,~T ~~'Q'`'~ - Q~~ - However I have changed my domiule
~ ° _ _~C~. f
iStreet and Number) ~ ~
so and am and have been a bona fide resident of the State of Florida since ~ l~/- - day ot !
,
, , 19~~ , and I reside at `~C~. 7 ~~8 - - .
~ (Street and Number)
~
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
~nd this statement is to be taken as my declaration of citizenship, actuat legai residence and domicite in the State of Florida.
(Insert here any pertinent facts, such as sale of property or business, or relinquishmenf of employment
at former domicile, removal of family to new dom}cite, purchase of home, etc.)
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/~:':tLL- "`'-'l' FILED aN[~ RECOROED ~y ~
- ST lUC1E COUMTY fLA. ~n
ROCE~ POITRAS
~ • j~ CLERK C:iCUlT COURT =
~ ~ y~~~~c ~•oaQ-~~ RFCGR~ v:'F,tFtED '
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OcT 13 II 2s AH'11
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I FURTHER CERTIFY that 1 wili compiy with all other requirements of a legal resident of this State.
I Fi1RTHER CERTIFY that I have no intention to retum to my former domi~ile, and I intend to remain in FORT
' PIERCE, SAINT LUCIE COUNTY, FLORIDA, perma~enNy.
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L'~-'-L~~l-t:z~__ _ c~r"~K- -
(Name)
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' Swom to and subscnbed before me this ' __1__~__ _ day of _ _ 19~. ~
,
- ROGER POITRAS ~ - - - - - - - -
CLEltK CIRCUIt C~URT Notary Pub(ic
. ~.t`u~ _ O.C. My Commission exp~res -
ey
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- ~ (To b~ NcecuMd in duplicate snd o~iginsl filed with Cl~tk Grcuit Court, and dupliut~ with Tax Assessor•}
~ ga~K 196 P~~E 976
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