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DeClaration ot Domicile and Cltizen$hip
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TO THE STATE AND COUNTY TAX ASSESSOR, ~
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Sl. IUCIE COUNTY, FLORIDA:
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This is my declaration of Domicile and Citizenship in the State of Florida that 1 am filing this day in accordance and
~n conformity with Chapter 222, Settion 222.17, Florida Statutes.
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I was formerly a legal resident of _ 1_
~C;ty~ (State)
However I have chan ed m domicjle
and I resid~d at 3 0 ~~H Ln! 9 Y
(Street and Number)
to and am and have been a bona fide resident of the State of Florida since ~~4~~ _ day of
_ . _ , 19?~ , and i reside at f~~ _ _ !a~_Q.? ~110 _~-S ~
(Street and Number)
FORT PIERCE, SAINT lUC1E COUNTY, FLORIDA V`'~"~ /~/4 "
and this statement is to be taken as my declaration of citizenship, actual iegal residence and domicile in the State of Florida.
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(Insert here any pertinent facts, such as sale of property or business, or reli~quishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
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~..t~~ FIlEO ANO RECORDEO
St.IUC~E COUNT1f FLA. C
; ~ ROCE^ F~ITRAS
; CLERK CtinCU1T COUIIT
' RECOR~ V~R!f1ED
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I FURTHER CERTIFY that I will comply with all other requireme~iis of a:ega! •esiden! of this State.
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~ I FURTHER CERTIFY that 1 have no intention to return to my former domiCile, and I intend to remain in FORT
~ rititc:r, ~P?fivi CuCir Cvui~iiY, FIVK~DH, permanently_
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~ ~ . (Name) ~'l~G~~q ~~PCC T
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- ~rSvir~y fa-bnd subscribed before me this day of , 19...~?~
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ROGER POITRAS _ -
~w; CLERK CIRCUIT COURT , Piotary Public -
By ~3~1L - D.C. My Commission expires
(To be exscuted in duplicats and oripinsl filed witb Clerk Grcuit Court, and dupliut~ with Tax Assasso?.)
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