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Declaration ot Domicile and Citizenship '
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TO THE STATE AND COUNTY TAX ASSESSOR, 22135 ~
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Sl. LUCIE COUNTY, FlOR1~A: . ~
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This is my detlaration of Domicile and Citizenship in the State of Florida that I am filing this day in accordante and ~
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~n conformity with Chapter 222, Section 222.17, Florida Statutes. ~
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I was formerly a legal resident of ~~S.ry~!~~l ---s~-
- - - - (Ciry) - - - (State) ~
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and I resided at ~r~1 SS (.QS~~~~ ~OX ~+?o~ /1 Q~ However 1 have cha~ged my domiGle
(Street and Number)
to and am and have been a bona fide resident of the State of Florida since ~~r~~6~r 3f_ day of
Dt~~ ~,x 6et- ~0.25" ~s /¢~ra~e ~ks7~ j~ I`' C: ~erc e, /-~/q .
_ _ . , 19_~1~_ , and I reside at - -
(Street and Number) 33 ys~
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
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and this statement is to be taken as my declaration of citizenship, actual legal residence and domici~e in the State of Florida. ~
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(Ir,sert here any pertinent facts, such as sale of property or business, or relinquishment of employment
at former domicile, removal of family to new domicite, purchase of home, etc.) '
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FILEO A!tQ RECORoED ~
ST.IUC~C COUNTY FIA. ~
~ R4CcK ~ ~~TRAS ~
~ CIEkK C.:.CUIi COURT ;
E RFCf1RD YE~.~F+E~~..,....~~ ~
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: ~AII 3 IO 34 AN'72~
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~ I FURTHER CERTIFY that I will 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 retum to my former domiule, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. ~/I
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. - • . . , 7~~LY
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~ (Name) ~
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- ~ ~ . ~ ~ - ,2 c ~ ~ ,~Sp/Q~c~ ~e Ll/u-t~, ~c~`~ /-.~i,t.:z~c ~/q , #
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Sworn to and suburibed before me this ~ day of ~~`h , 19 Z--- ~
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- ROGER POITRAS _ ~
K CIR~Id~ COURT Notary Public ~
B D.C. M Commission expises ~
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' (To be sxecuted in duplicate snd oriyinal filed with Cl~rk Grcvit Courf, and duplicate with Tax Ass~ssor.) ~
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aoo~ 198 ~~~E 1328
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