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Declaration ot Domicile and Citisenship
TO THE STATE AND COUNTY TAX ASSESSOR, A
IG?IV •3
Sl. LUCIE COUNTY, FLORIDA:
This is my declaration of Domicile and Citizenship in the Sta~e 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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I was formerly a legat resident of _ __~-Q-~t~ "~r~
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% (C~y) ate)
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and 1 resided at _~1 _~9C^ _ -Q4"_`r_ . However 1 have changed my domitile
~ (Street and Number)
to and am a~d have been a bona fide resident of the State of Florida since _ _~~`~L _ day of
~~~e'~?~L.3t'~=v 19~~and I reside at Nn~ V-~-[l_2.?~~(__-
(Street and 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.) ~
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CtERK Gt?~~~~ ~OURT ~
RECORD vEFrFlc~1
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~ I FURTHER CERTIFY that I will comply with all other requiremenis of a lega) resident of this State.
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~ I fURTHER CERTIFY that I have no intention to return to my former domitile, and I intend to remain in FORT
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~ PIERCE, SA!{~T E~JCIE ~OUNTY, FLORIDA, permanently.
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Swom~ to and subscribed before me th~s day of ~ , 19
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- ROGER POITRAS
C CIRCUIT COU Notary Public ;
~ By _ iG~'l ~ .C. My Commission expires
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(To b~ ~xecvt~d in dupliute snd oriQinsl ~iled with Gl~ric Grcuit Court, and duplicate with Tax Assessor.) ~
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a~oK 199 357 i
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