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Declaration ot Domicile and Citizenship r
Tb THE STATE AND COUNTY TAX ASSESSOR, ~~~~SS
Sl. IUCtE COUNTY, FLORICA:
This is my declaration of Dom~cile and Citizensh~p in the State of Ftorida that 1 am filing this day i~ accordance and
~n conformity w~th Chapte~ 222, Section 222.17, Florida Statutes.
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I was formerly a legal ~esident of ~L2~ ~t.~. k,)
~C;ty~ (State)
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and 1 resided at ~ ~4-s~s-~ _ However I have changed my domiG~e ~
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(Street and Number) ;
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ro and am and have been a t~ona fide resident of the State of Florida since ~~L / - - Y
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- ~J ~ ' , 19~~, and I reside at ~1 lt ~ - -
(Sireet ar.d Number)
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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 domicile in the State of Florida. ~
(Insert here any pertinent fatts, such as sale of properry or business, or relinquishment of employment
at 4ormer domicile, removal of family to new domicile, purchase of home, etc.)
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FILED AND RECOROED
iT. lUC1E COUNTY FLA_ ~
ROCEIi POITRAS tQ
CtERK CfRCUIT COURT
RECQRC V:R~FIEO P
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~ ~AN ~0 02 ~'~t
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~ 2%~1455
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~ 1 FURTHER CERTIFY that I will comply with all other rcquirements of a legal resident of this State. ~
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~ I FURTHER CERTIFY that I have no intention to retum to my former domiG~~, and 1 intend to remain in fORT ~
~ PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently_ ~
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~ - . (Name) Qi f/re i+~ ~
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_ • (Address) ~
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Swom to' ~d subscribed before me this ~ day of - - , 19_1__~.! ~
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ROGER POITRAS '
CLERK CIRCUIT COURT Notary Public :
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gy _ _ t D.C. My Commission expires ?
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(To bs sxxuted in duplicate ~nd oriyinal filed with tl~rk Grcuit Cou?t, and dupliute with Tax Ass~ssor.) ~
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70
`~o. 13
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