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Declaration ot DomiCile and Citizenship
TO THE STATE AND COUNTY TAX ASSESSOR, ~
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51. IUCIE COUNTY, FLORIDA: ~~+~C73
This is my declaration of Dom~cile and Citizenship in the State of Florida that I am fili~g this day in accordance and
~n conformity with Chapter 222, Sect~on 222.17, Florida Statutes.
1 was formerly a legal resident of ~ApD~ ~ H~_.
_ (City) - ~tate)
and I ~es~ded at _ ~_6_3 a S~cA~yo i2E,_-~`T However I havechanged my domiG~e
(Street anrl Number)
3
ro and am and have been a bona fide resident of the State of Florida since N° ~ S~~____ day of :
~
19_ and I reside at 1~A ST''4"`~ C i, t/7- S~_ L.,s c._~ `
_ _ _ _ -
(Sireet and Numberl
FORT PIERCE, SAINT IUCI~ COUNtY, ~ORiDA
and this statement is ta be taken as my dec{aration of citizenship, actual legal residence and domicile in the Stafe of Flarida.
(Insert here any pertinent facts, such as sale of prope~ty or business, or reli~quishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
,
fIIED tli;~ RECOROE~
ST. LUCtE COUlITY flA.
1lOCE~ PJITRI?S
CLERR C~~'CU~T CAURT ~
RECQRQ YFF:f~EO~~
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~ I RIRTHER CERTIFY that 1 will comply with all other requirements of a legal resident of this State.
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~ 1 FURTHER CERTIFY that 1 have no intention to return to my former domicile, and I intend to remain in FORT
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~ PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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r:' (Name)
~ Rodc~er- ecrsonr
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- ~Swosn~to and subscribed before me thi day of , 19~
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N~: ROGER POITRAS
CLERK CIRCUIT COURT Notary Public
By D.C_ My Commission expires
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(To b~ ~xecuNd in duplicate snd ori~inaf fil~d with CiKlc Grwit Cot~rt, and duplicat~ with Tax Ass~stor.)
,3 ~198 ~~1~5
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