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Declaration ot DomiCile and Citisenshlp
TO THE STATE ANO COUNTY TAX ASSESSOR. 222012
Sl. IUCIE COUNTY, FIORIDA:
ihis ~s my declarat~on of Domicile and Citizensh~p in the State of Florida that 1 am filing this day in accordance and
;n confo~mity with Chapter ?22, Section 222.17, Florida Statutes.
1 was formerly a legal ~esident of _
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(Ciry) (State)
and I ~esided at ~d~~ 'r_~ However 1 have changed my domiCile
(Street and Number)
fo and am and have been a bona fide resident of the State of Florida sinc~ _ day of
_ , 19~~ , and I reside at U ~
- - -
- - - - - ----U treet and Number)
rvR~ ~i~~i~E, aiaii~i i iva:ie a`:a~iiii~i~Y, ~t3~ius?
and this statement is to be taken as my declaration of citizenship, actual ~egal residence and domicile in the State of Florida.
(Insert here any pertinent facts, such as sale of properry o~ business, or relinquishment of employment
at former domicile, removal of family to new domicile, pu~chase of home, etc.)
.
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i rUitiiitK L~ciifY that i wi'ti compiy with alI other requirements of a iegai resic~ent ofi this State.
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~ 1 FURTHER CERTIFY that I have no intention to return to my former domic,ile, and I intend to remain in FORT
PIERCE, SAINT LUUE COUNTY, FLORIDA, permane~tly.
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_ 'SworN to and subscribed before me this _ day of - , 197Z .
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ROGER POITRAS _ _
K CIRCUIT tOURT Notary Public
By ~ D.C. My Commission expires
3
(To b~ executed in dupliute and original fil~d with CIe~1c Grcuit Court, and duplicst~ with Tax Ass~sso~.)
~ „ ° R 1y8 P~~E2247
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