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Declaratlon ot Domicile and Citisenship
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TO THE STATE AND COUNTY TAX ASSESSOR,
Sl. IUCIE COUNTY, FLORIDA:
This is my declaration of Domicile and Citizenship in the Sta~e of Florida that 1 am filing this day in accordance and
~n conformity with Chapter 222, Sectio~ 222.17, Florida Statutes.
t was formerly a legal resident of ( °Lr_1 _.~1 A ltii - _ - - - 7'.~j 55
(City) (State)
a:xi 1 resided at C Nowever 1 have changed my domici~e
(Street and Number)
to and am and have been a bona fide resident ot the State of Florida since _ _ ~_I _ day of
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~f and I reside at ~ -3 ~_.L~ /9 !,c! ~ 1 ~ A C •
(Street and Number) .
FORT PIERCE, SAINT LUClE SOUNTY, FLORIDA
and this statement is to be taken as my declaration of 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 employment
at former domicile, removal of family to new d~micile, purchase of home, etc.)
C~lit L~lZ'tf-s1i !Q"~_ ~s-p-~ ~
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FILEO AMO ~ECOROEt C(~
St. R~
~~R FONRAS`A.
~i CIERK C«tCU1Z COURT~
; RfCOR~ YEf.'F1E0.1~
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~ 1 FURTHER CHtTIFI( that 1 will comply with all other requirements of a legal reside~t of this State.
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w I FURTHER CERTIFY that I have no intention to return to my former domi~ile, and 1 intend to remain in FORT
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~ PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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'4 Sworn ~t~and suburibed before me this day of ~~'U ~ , 19Z. ~
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RAGER POITRAS
CIRCUI COURT Notary Public
G.-c~c.(~ ~G'L~.l~~
yV B D.C. My Commission expires
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(To b~ ~xecut~d in dupliuts and ori~inal ~ilad with GKk C~rcuit Gou~f, and du iiut~ with Tax Ass~s*or.)
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