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Declaratio~ ot Domicile and Citizenship
TO THE STATE AND COUNTY TAX ASSESSOR, 2~~88
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51. lUC1E COUNTY, FIORIDA:
This ~s my dec!arat~on of Dom~cile and Citizenship in the State of Florida that I am filing this day in accordance and
~n conformity with Chapter 222, Section 222.17, Florida Statutes. !
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I was farmerly a ~egal resident of _ _ _
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(City) (State)
and I resided at _~~3 Y~'~--~~ However 1 havechanged my domiCile
ii~~ (Street and Number)
ro and am and have been a bona fide resident of the State of Flo~ida since l~ - day of
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, 19~~ , and I reside at ~f _ ~ ' _ _ -
(Street and Number)
F~KI 1'1lK6t, ~AIIVI LtJ~lt ~.V111V11, rLVK1YA
and this statemeni is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Florida_
(Insert here any pertinent facts, such as sale of property or business, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
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i FIlEO ~?'~D ~ECOROEO '
% ST_ WC~E GOt~ITY fLA. .
' ~C a~Gc o+~ , ROCER P~ITRAS (
F CLERK C~~•GUI~ COURT~~ '
t PEGrR't Yco~rtEO~.~.-~{~~
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~ f Ft1RTHER CERTIFY that 1 wiii comply with ail other requirements of a iegal resicient of this State.
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~ I FURTHER CERTIFY that I have no intention ta return to my former domi~ile, and I intend to remain in FORT
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~ PIERCE, SAINT LUCIE COUNTY, FLORIDA, perm~.iently.
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~ - ~ (Name)
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M (.Jj _='in t~ -~j'~-~~ . .
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= - G` ~ . ~ 's - (Address) - -
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,yz !~,~'1 .~~`'subscribed before me this da of ~ , 19~_~
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"`j` ROGER POITRAS
- CLERK CIRCUIT COURT Notary Public
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gy G !it Cl-~ D.C. My Commission expires
(To be executed in duplicate and ori~inal ~led with Cl~rk Circuit Court, and duplicat~ with Tax Assessor.)
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