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Declaration ot Domtcile and Citizenship
TO THE STATE AND COUNTY TAX ASSfSSUR, 2~;~'~1~~~
51. lUC1E COUNTY, FIORIDA:
This is my declaration of Dom~cile and Citizenship in the State of Florida that I am filing this day in a~cordance and
~n conformity with Chapter 222, Section 222.17, Fto~ida Statutes.
t was formerly a legal resident of ~j~S T._ (.2'1~~~N~~~~~ ~
1 _ - ~ _ _
(C;ty) (State)
and 1 resided at / l~~~~%!~ T~~l~_ - However I have changed my domicjle
(St~eet and Number)
to and am and have been a bona fide resident of the State of Flo~ida since _ day of
- , 19_~1 ~ and 1 reside at !_S S ~ __c'~~~'~~~~ ~U~- - -
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, FtORIDA
and this statement is to be taken as my declaration of citizenship, actual legat residence and domicile in the State of Florida.
(Insert here any pertinent facts, such as sale of property or business, or relinquishment of employment
ai former domicile, removal of family to new domicile, purchase of home, etc.)
FILEO AN~ RECORaEO
j ST. LUClE COUNTY FLA. ~
~ ROGEa PO~TRAS
CLERK C s"•CUl7 COUtiT
RFI;CP,[` Vr -.~ILC
F ~Atl ~ ~ ~ 27 ~K'ZZ
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k 1 FURTHER CEftTIFY 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 return to my former domicile, and I infend to remain in FORT
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~ PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently_
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- (Address)
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= Svraln and subscribed before me this day of - , 19~
ROGER POITRAS
C K CIRCUIT COURT Notary Public
By ~ D.C. My Commission expires
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~ (To be executed in duplicate and original ~iled with Cl~rk Circuit Court, and dupliute with Tsx Ass~ssor.)
~ 198 1494
F'ry No 13 A ~oY11 PAGf