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Declaration ot Don~icile and Citizenship
TO THE STATE ANI~ COUNTY TAX ASSESSOR, ~~2^ pS ~
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Sl. lUC1E COUNTY, FLORI~A
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This ~s my declaration of Domiule and Citizenship in Ihe State of Florida that 1 am f~lmg this day in accordance and
;n conformity w~th Chapter 222, Section 222.17, Florida Statutes
.
I was formerly a legal resident of '~1 1 1'1 ~.i~ ~ -
(City) (State)
and I resided at Y~ 1_~ However ! have changed my domiCile
(Street and Number)
~
!o and am and have been a bona fide resident of the State of Florida since ~ J day of
7~ }~~kr.,5 ~ ~c.i~ t.~
~
J l ~ . 19_~~. and 1 reside at ? ~ ~ ~ c• ~r e ~ _
(Street and NuFnber)
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
and this statement is ro be taken as my declaration of citizenship, actual legal residence and domi:ile 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.)
fllEU •h^ ';COiOED
ST. LUCtf "L:!)NTY FLA.
' P~G~; )~7RAS
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~ I FURTHER CERTIFY that 1 will comply with all other requiremenfs of a(egal resident of this State.
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~ I FURTHER CERTIFY that I have no intention to retum to my former domic,ile, and I intend to remain in FORT
~ PIERCE, SA1NT LUCIE COUNTY, FLORIDA, permanently. j
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- . - - - ~ 4 J ~
::3 • - (Name) y
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Swom to and subscribed before me this 1_----_ _ day of ,~,:,c~ 1~ ~ c«~ , 19~~
-
ROGER POITRAS
CLERK CIRCUIT COURT Notary Public
~
= Bv _~1L-~- D.C. Mv Commission exoires _ _ .
_ . t, ~ . .
(To be sxecuted in duplicate and originsl filed with Clerk Circuit Court, and duplicsts with Tax Assessor.)
rio 13 BGCK 198 F~~iE
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