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Decla~atio~ ot Don~icile a~d Citisenship
TO THE STATE AND COUNTY TAX ASSESSOR, i~
Sl. IUCIE COUNTY, FlOR10A:
22'1881 ~
This is my decla~ation of ~omicile and Citizenship in the State of Florida that I am filing this day in accordance and
~n conformity wi~h Chapter 222, Scction 222.17, Florida Statutes.
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I was formerly a legal resident of _ / - - ~1 - ~
(City) - (State)
and 1 resided at 1~~~~ ~L
~L~~ _~l"_.L-_-_- However I have changed my domici~e ~
(Street artd Number) ~ ~
ro and am and have been a bona fide resident ot the State of Florida since (J_. day ot ~
i;c~=~ ~4~ ~ ~-j - - 19~_~, and I reside at /~v~ ~ ~ - - - `
U (Sireet a Number)
/ fORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
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.) j
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ROGER ?~~Y~~$
, 11ECOR0 VER~tFtEO CO~Rj
~ ~I?111 ~ 04 ~
~ 221851 ,
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~ I FURTHER CERTIFY that I will rnmply with 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 domiCi~e, and I intend to remain in FORT
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~ PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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. . . ' ~ (Name) k ~ ?SC h
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- Sw~oth to and subscribed before me this r~ day of ~ , 19~2~
- ROGER POITRAS
~ CLERK CIRCUIT COURT Notary Pubiic
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By D.C. My Commission expires
_ (To b~ ax~cut~d in dupliuts and ori~inal filed with C{e~lc G~cuif Court, and duplicate with Tax Ass~ssor.)
~~'y~s ~LYT i~
No. IJ
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