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~eclaration ot Domicile and Citisenship
TO THE STATE AND COUNTY TAX ASSESSOR, •
~2161~
Sl. LUCIE COUNTY, FLORIDA:
This ~s m cfeclaranon of Dom~ute and Cit~zensh~ in the State of Florida that I am filing this day in accordance and ~
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;n conform~ty with Chap~er 222, Sect~on 222.17, Florida Statutes
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t was formerly a legal resident of ~~~t~z~? ~ ' }
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and 1 resided at T- ' / - _ riowever I have changed my domiGle
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(Street and Number)
1o and am and have been a bona fic~e resident of the State of Florida since _ _l.~_~._!T_~ day of
_ _ _ , 19_ , and I reside at - l__~ _ _~_~-e.~•!= ~ L-~ - -
(St~eet and Number)
FORT PIERCE, SAINT LUCIE COUNTY, RORIDA ~
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 saie of property or business, or relinquishment of employment ~
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at former domiule, remova! of family to new domicile, purchase of home, etc.) ~
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FILED 4Kp KECORDEO
ST. LttCIE COUNTr FIA.
C1ER+~C fi,CUlT COURT ~ ~
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RE~ORG '.•_;,t~1E[~
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~ I FURTHER CERTIFl( that I will comply with all other requirements of n, leyal resident of this State. ~
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~ 1 FURTHER CERTIFY that I have no intention to return to my former domiG~e, a~d I intend to remain in FORT
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~ PlERrE, SAINT LUGE COUNTY, FLORIDA, permanently. ~
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y (Name)
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~ Swom to and subscribed before me this day of _ , 19~! ~
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ROGER POITRAS
CLERK CIRCUIT COURT Notary Public
By ~ D.C. My Commission expires
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- (To be executed in duplicaro snd oriQinaf ~iled with C{Kic Grcuit CouA, and dupliute with Tax Ass~s~or.)
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