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Declaration ot Dor~icile and Citizenship ~
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TO THE STATE AND COUNTY TAX ASSESSOR. ~ ,
Sl. lUC1E COUNTY, FIORIDA: t
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This ~s my declaration of Domicile and Citize~ship in the State of Flo~ida that 1 am filing this day in accordance and
~n tonformity with Chapter 222, Settion 222.17, Florida Statutes. j
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1 was formerly a lega) resident of .~~~~~1~~- ~~1-d
(City) ^ (State)
and I resided at _Z_! `~!g~'}1~~/~___~Sl~_--__._ . However I havechanged my domicile
(Street and Number)
to and am and have been a b~na fide resident of the State of Florida since f-~t'i -o~- - day of
f1 / ot 3 I~~ ~',t'ES Ti~ l7,e ~vE O~s~:_ `~•-~-~.c~
-'-~~--QC --CL l~~i~ - - 19~ , and 1 reside at ----1-
` (Street and Number)
FORT PIERCE, SAINT LUCIE GOUNTY, FIORiDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Florida.
(I~sert here any pertinent fads, such as sale of property or business, or relinquishment of employment
at former domicile, removal of family to new damicile, purchase of home, etc.)
~ (.G(~C`~-"~;~2~ ~~~2~l.Cfii-!'"`"~y
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- ResE~ .~~.T~~?s
C:E~.R ::.UIT COJRT L
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~ I FURTHER CERTIFlf that I wil{ comply with all other requirements of a legal resident of this State.
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~ I FURTHER CERTIFY that I have no intention to return to my former domi~ile, and I intend to remain in FORT
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~ PIERCE, SAtNT_ LUGE COUNTY, FLORIDA, permanently.
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. _ - ~ ~ (Name) .
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- ~Swom`to and subxribed befor~ me this day of , 19~.
_ ROCsER POITRAS
CtRCUIT COURT Notary Public
By ~~~'~~`-Ll~~ D.C. My Commission expires
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_ (To b~ ~xscuted in dupliute and ori~inal ~il~d with GKk Grcuit Court, and duplicsb with Tax Assessor.)
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