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Declaratio~ ot Domlcile and Citizenship
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TO THE STATE AND COUNTY TAX ASSESSOR,
51. lUC1E COUNTY, FLORIDA-
This is my declaration of ~om~cile and Citizensh~p i~ the State of Florida that I am filing this day in accordance and ~
,n conformity with Chapter 222, Section 242.17, Florida Statutes. ~
1 was formerly a legal resident of L ` , ~tt _ - - ~~'-L ' -
~ (City) ate)
and I resided at dk.4~ s*-f~~`---____ _ However I have changed my damiCile
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(Street and Numbe~)
to and am and have been a bona fide resident of the State of Florida s+nce i!~~''~ - da of
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- - - - - - - . ~ 9_ ~ f , and ! reside at ~ =i----~~ ~~tCt tl ~ ~
(Street and Num~er)
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
and this statement is to be taken as my dectaration of citizenship, actual tegal residence and domicile in the State of Florida.
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(I~sert here any pertinent fads, such as sale of property or business, or relinquishment of employment
at former domicile, rerr.oval of family to new domicile, purchase of home, etc.)
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~ I FURTHER CERTIFIf that I will comply with all other requirements of a lega) resident of this State.
1 fURTHER CERTIFY that t have no intention to retum to my former domiule, and I intend to remai~ in FORT
~
~ PIERC~, SAJTyJ},LU~1E COUNTY, FLORIDA, permanently.
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yv Swom tu and subu~ibed before me this _ - day of ~~-t-~ _ , 19~?~
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ROGER POITRAS -
CIFitK CIRCUIT COURT Notary Public
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By D.C. My Commission expires ~
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- (To be ~xecuted in dupliute aed original filed with CIKIc Circuit Cour~, and duplicsts with Tax Asssssor.)
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