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Declaration ot Domicile and Cltizenship
TO THE STATE AND COUNTY TAX ASSESSOR, ~
2 9~4~0 ~
Sl. LUCIE COUNTY, FLORIDA~ 3
This is m declaration of Domicile and Citizenshi in the State of Florida that I am filing this day in accordance and ~
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~n conformity with Chapter 222, Section 222.17, Florida Statutes. "1 - ~
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1 was formerly a legal resident o - - - _ - - L~ - -
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and I resided at-~~~' ~-rV However I have changed my domicjle
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to and am and have been a bona fide resident of the State of Florida since 3 d of
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- - , 19~~ , and I reside at - - - - ,
(Street and Number)
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FORT PIERCE, SAINT LUCIE COUNTY, FtORIDA ~
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 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 FURTHER CERTIFY that I will comply witfi 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 domicjle, and 1 intend to remain in FORT
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~ PIERCE, SAINT LUCIE COUNTY, FLORIOA, permanently. ~
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Sworn'to and subscribed before me this day of ` , 19~
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= ROCsER POITRAS `
; K CIRCUI COURT ' Notary Public ~
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By ~ D.C. My Commission expires
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~ (To be executed in duplicate and ori~inal filed with Clfrlc Grcuit Courf, and dupliute with Tax Asaessor.) t
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