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D~ctara~ti+~n ot D~r~iciie and Ci:iz~.~~:::~.
TO THE STATE A~.D C~UN'+Y 7AX ASSESSOR. 2181.03
~i. LUGE COU~ITY, FIO~~DA:
~n~s :s my de.taratipn of Domit~ie and Citizenship in the Stare of F:or+da that 1 am fii~ng this day in accordance and
n con4ormity with Chapter 222, Sect~on 222.17, Fforida Stat~tes.
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i was formeriy a ~egal resident of - ~ ~
~C~ry} tate)
a~d 1:es:ded at F:~ t_#/__---i~~13.4LL-~~~"~'---- - Kowever 1 have changed my domi4le ;
(Street and Number)
and am and have been a bona f+de ~esident of the State of Ftorida since _~_sr_~- S! _ day ot
_ - _ 14~~__, and 1 reside at _ 6 ~ ~ `r ~ •
- - - - -
(Street and Numbe~)
=ORT PiERCE, SAINT LUCIE COUNTY, FLORIDA
ar.d tn~s statement is to b~ taken as my deciara~ion of utizensh~p, actual iegal residence and dom;cife in ihe Staie of Fiorida.
(lnsert here any pertinent facts, such as safe of property or business, or relinquishment of employme~t
at former domic~le, removai o4 fami{y to new domicile, purchase of home, etc.)
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1 FURTriER CERTIFY that ! w~1i compiy with a(I o~her requiremenis of a le~ai res~clent of tnis State. '
_ ,
= t F::RTr1~R CER i~FY shat I~ave no ir~sent:on to retum to 'my former domici!e, ar,d I intend to remain in rO~ZT
V? ~,~RCE, SF,1VT IUCiE CO~NiY, FLORIDA, permanentiy.
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(Address} ;
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`i Sncom to ar.d substribed before me this ~ day of ~~:~~;-'~'-i=~- h`" .~9~.
~ ROG~R POITRAS. ~
F Ct~RK GIRtUI'~~OURT Notary Pu~t,c
- - ~ - C, c~.,cc~-~/ D.C. My Ccmmission exp~res
~y
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(7o be executed in dupticate and original filcsd with Clerk Circuit Court, ind duplicalo with Tax Assas:or.) ?
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