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Deciaration ot Domicile and Cttizen~thip
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TO THE STATE AND COUNTY TAX ASSESSOR,
Sl. lUC1E COUNTY. F~oR~oA: 221353
This is my declaration of Domicile and Citizenship in the State of Florida that I am filing this day in accordance and
~n conformity with Chapter 222, Section 222.17, Florida Statutes.
1 was fo~merly a legal resident of . NS~ _ _ _ ~__LV~/ A~!_J~
(Ciy) (State)
and 1 resided at _ _ /1/. __~~/?~'1 __~7~ _ However I have changed my domiGile
(Street and Number)
to and am and have been a bona fide resident of the State of Florida since ~~f?~~~ -T t_ day of
- -~~c7 E~1 _ - . 19_7 / , and I reside at !s~1Q - ~u~A 5 ~C',~ A A.
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, RORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Florida_
(Insert 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.)
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ST. lUC1E COUNTY Fl~l.
ROCER FOITRAS ~
CLERK CIRCUIT COURT
RECORO YERIFIEO..~.~
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~ I FURTHER CHtTIFY that 1 will comply with all other requirements of a legai resident of this State.
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; t FURTHER CERTIFY that I have no intention to return to my former domiGle, and I intend to remain in FORT
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~X PIERCE, SAINT IUCIE COUNTY, FLORIDA, permanently_
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~Y " (Name) (T c~. a d w c~Z
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x .,~wom to and subscribed before me this ~ day of ~ T- - , 19~L-
- ROGER POITRAS _
CLERK CIRCUIT COURT Notary Public
_ gy S~L _ D.C. My Commission expires
(To be ~xecuted in dupliute and original ~iled with Cl~vfc Grcuif Couii, and dupliute with Tax Ass~stor.)
, 3 ~ b~?K ~98 ~325
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