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Deciaration ot Domicile and Citizenship
TO THE STATE AND COUNTY TAX ASSESSOR, • ~ ~
22163'7
Sl. LUCIE COUNTY, FIORIDA:
This is my declaration of ~omicile and Citizensh~p in the State of Florida that 1 am filing this day in accordance and
~n conformity with Chapter 222, Section 222.17, Florida Statutes.
I was formerly a leqal resident of ~
~~;~y~ (Stat
and 1 resided at L_~~ `-~n~~ ~ Nowever 1 have changed my domicjle
(Street and Number) - ~
ro and am a~d have been a bona fide resident of the State of Florida since _°_I~ day of
~aC~t,~~-t~- ~ ll m'1 11~,c-~-Zt-~
_ - _ , 19 7_ and I reside at ---`3 "-=r'-- y - - -
(Street and Number)
fORT PIERCE, SAINT LUCIE COUNTY, KORIDA
and th~s statement is to be take~ as my declaration of citizenship, actval legal residence and damicile 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.)
FILEO AkD aEC0~0ED
' ST.lUC1E COUMTY FLA. s
i ROCER ~OITR~S ~
E CLERK C!!:CUIT COU11T !
~ RECORD YF~~f ~ED
~ ~AN 6 2 18 ~~'~Z
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~ 22163'7
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~ 1 FURTHER CERTIFY that I will comply with al) other requirements of a legal resident of this State.
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~ 1 FURTHER CERTIFY that I have ~o intention to return to my former domic,ile, and I inte~d to remain in FORT
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~ PIERCE, SAINT LUCIE COUNTY, FLORIDA, permane~tly.
,GG~~ ~ lC~~u'`'~~ t-a,
(Name) (Jt^atx.~ E ~S
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. ~y~ rn. 1~-:~..~pt ~
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~ Sworn ~to•and subscribed before me this _ day of 19~
r~
ROGER POITRAS
CLERK CIRCUIT COURT Notary Public
gy D.C. My Commission expires
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(To be executed in duplicate and o?i~inal filsd vrith Clerk Grcuit Court, and duplicat~ with Tax Assessor.)
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