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Declaration ot Domicile and Citi:enshlp ~
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221258 ~
TO THE STATE AND COUNTY TAX ASSESSOR, ~
51. IUCIE COUNTY, FLORIDA:
This is my declaration of Domicile and Cit~zenship in the State of Florida that I am filing ihis day in accordance and
~n conformity with Chapter 222, Section 222.17, Florida Statutes.
I was formerly a legal resident of _~aarborn Yichigan ~
_ -
(City) (State)
2491? Winone Jrive
and I resided at _ - - - _ _ _ . However 1 have changed my domicjle
(St~eet and Number)
to and am and have been a bona fide resident of the State of Florida since _.?Oth day of
October ~q_?1_, and I reside at ___80 El l6ar Dive, Jensen ~c, F_ la.. ;
- - - -
(Street and Number)
FORT PfERCE, SAINT LUCIE COUNTY, RORIDA
and this statement is to be taken as my declaration of citize~ship, actual legal residence and domiciie in the State of Florida.
(lnsert here any pertinent facts, such as sale of property or business, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
Eatablis~ing reainence 22~8
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~ I FURTHER CERTIFY that I will comply with all other requirements of a teflal resident of this State.
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~ I FURTHER CERTIFY that I have no intention to return to my former domicjle, and I intend to remain in FORT
~ VIERCE, SAINT LUCIE COUNTY, FLORIDA, rmanentl ~
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q4~ - (Name)
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Sworn ta and subscribed before me this 3~~L- day of December , ~9_3.1 ;
- ROGER POITRAS
LERK CIRCUIT OURT Notary Pubiic
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_ By _ D.C. My Commission expires
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_ (To b~ ~xecuMd in duplicat~ and oripinal ~il~d with CI~ir1c Circuit Court, and duplicat~ with Tax Ass~ssor.) ,
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