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DeCiaration ot Dort~iCile and Citizenship
~O THE STATE AND COUNTY TAX ASSESSOR,
2zzoso
51. LUCIE COUNTY, FLORIDA:
This ~s my declaration of Domicile and Citizensh~p in the State of Florida that I am filing this day in accordance and
~n conformity with Chapter 222, Section 222.17, Florida Statutes.
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t was forme~ly a legal resident of ~ g~ _ Lr~
_~~0-t4~ C1~.~ ~r'~s.~Q-
(City) (State)
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and I resided at _.RZ__ However I have changed my domicjle
(Street and Number) `
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~o and am and have been a bona fide residem of the State of Florida since ~,pGy day oi ;
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. ~1J~ ~c~ , 19_~~ _ _a~~ _ T--l~ ~ L-e-«l" _ a
and I reside at i
(Street and Number) z
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~ltT PlERCE, SAENT LUCfE CQUNTY, fiQRlDA ~
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and this statement is to be taken as my declaration of citizenship, actual legal residence and damicile in the State of Florida. ~
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(Insert here any pertinent facts, such as sale of property or business, or relinquishment of emp~oyment ;
at former domicile, removal of family to new domicile, purchase of home, etc.)
fIlEO ANO 4ECORDEO
ST.IUCIE COUNTY ft~. .I
ItOCE~ FO?TRAS
CLERK C:°CUtt COURT
RFCOqD YEE~~'iED
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; I FURTHER CERTIFY that I will comply with all other requirements of a legal resident of ihis State.
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~ 1 FURTHER CERTIFY that I have no intention to return to my former domiGile, and I intend to remain in FORT
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PIERCE, SAINT WCIE COUNTY, FLORIDA, permanently.
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~ ~ ~c Cett
(Name)
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= Sworn to and subscribed before me this ______L~___ day of _ , 19~~~> ;
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ROGER POITRAS _
LERK CIRCUIT COURT Notary Public
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6y ~X1C D.C. My Commission expires -
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(To be execut~d in dupliute and originai filsd with Cl~rk Grcuit Court, snd dupliuh with T~x Assessor.)
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- bODK 1~0 PACE~Vei
ho 13
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