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Decia~ation ot Dor~icfie a~d Cltizenship
j0 THE STATE AN~ CO~lN?Y TAX ASSESSOR,
Sl. LUCIE COUNTY. FLORIDA: + ~tiQ38O
This is my decla~st~on of Domicile and Citizenship in the Stste of Florid~ that 1 am filiny tfiis dey in ecaord~nw and ;
~n oonformity with Chapte~ 222, Section 222,17, Flor;da Statutes.
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I was formerly a leflal ~esident of d
Kity) (Stah) ~
and I resided at ~ ~i/~m~6/~?cr~~~`4. However 1 have chan~ed my domiCile
(Street and Number)
ro and am and F?ave becn a bona fide ~esident of the State of Florida since ~~1~Tif day of
-s"___~_E--~'' . 19~~ and 1 reside at c~~,~,.//.L~o~ ~~/e~E/
(Str ond Numbe~)
FORT ~IERCE SAINT LUCIE C UN ~S~E~E/~'iQI ~9~ ~
, O TY, flORi~A
and this statement is to be take~ as my declarotio~ af citizenship, actual legal residence and domicile in the State of Horida.
(Insert here any pertinent facts, such as sale of property or business, or relinquishment of empioyment
~t former domicile, removal of family to ~ew domicile, purchsse of hane, etc.)
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~ I FURTHER CERTIFY that 1 wil) oomRiy with all other requi~ements of a(esal residant of this Stats. i
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I FURTHER CERTIFY that i heve no intention to retum to my former domicale, a~d 1 intend to remain in FORT ;
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PIERCE, SAINT LUClE COUNTY, FLORIDA, permanently. _
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Sworn to anii su~aibed before me thi: dey of , 19~
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; ,ROGFtt ;~POITRJ?S , •
~s :CL~,1tK~CUIT CQ~fiT Notary Public
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_ gY ~ D.C. My Commissio~ expi~es
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`~5 lTo b~ ~x~artad in dupliua and orisinal fit~d with Cl~rk Gnvit Co++~, and duplicah witb Tax Ass~sso~a
~c~ s~ ~97 ~ 2740
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