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Declaratlon ot Do~nicile and Citizensh~p .
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TO THE STATE AND COUNTY TAX ASSESSOR,
221644
Sl. IUCtE COUNTY, FLORIDA:
This ~s my declaration of Dom~cile and Citizenship in the State of Florida that I am filing this day in attordance and
~n conformity with Chapter 222, Section 222.17, Florida Statutes.
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I was formerly a legal resident of -
~ (C;ty) (State)
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and I resided at _ ~ ~ ~ _ . ~ However I have changed my domicjle
(Street and Number)
to and am and have been a bona fide resident of the State of Florida since ~~j ~-1 - day of
_ - , 19__ , and I reside at ~ ~ ~ ` p~~`~C-_ _
(Sireet and Number)
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
and this statement is to be taken as my declaration of citizenship, actuai legal residence and domicile in the State of Florida.
(Insert he~e any pertinent facts, such as sale of property or business, or relinquishment of emptoyment
at farmer domicile, remova! of family to new domicile, purchase of home, etc.)
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~ 1 FURTHER CERTIFY that 1 will comply with all other requirements of a leyal resident of this State.
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~ I FURTHER CERTIFY that I have no intention to return to my former domiCile, and I intend to remain in FORT
~ PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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y ~.~'•f (Name) M b
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Sworn to`and suburibed before me this day of , 19~?~'
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ROGER POITRAS _ _
tLERK CIRCUIT COURT Notary Public
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° By ~ ~ D.C. My Commission expires
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~ (To be exscuted in dupliute and ori~inal Rled with Cl~rk Circuit Courf, and dupliut~ with Tax Ass~ssor.)
° R 198 ~E1?18
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