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Declaration ot Domicile and Citizenship
TO TNE ~TAIE AND CC?UNTY 1AX AJSE;SOR ~
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:i IUCIE COUNIY, FIORIC)A
~ii~s u n~} :ie~iaiar•~n ot Uo~~~~c:;e and C~tizenship in the State ot F1or~da ihat ! am "~:~:,y th.s ciay ~r a.cordance and
,_O~:fn.mity Yy:th ('harn,t.~r ?77 Cn, t;~.. ?77 17 ~I.J.:..:Id S?3!L'!@S
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t rvd5 f0ln~ffly d leyd~i !cS~C~efl1 Ot b "V ! ~ / ~ Lv~v~h ~ ~ ~ ~
(City) (Sfate)
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+^:ci I res~de:~ at ~ v +~J ~ S~ C/~ F 1~~` No~vever I ha~e changed my do*riUlP ~
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and arn and have be~s~ a bon~ fide resident of the Jtate of Florida s~nce ~~Y pt
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~ ~ ~ ~ ~ ~ ~ Q 19 ~ ( and I reside at a ~ ~ ~
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
+•,d th~s st3rer,,ent ~s ~o h~~ ;:~ken as my ~+eciarat~on of ntizenship, actvai lega! res+dence and domicile m the ~tate of Florida '
(Insert here any pertic,en~ fatt;, su:h as saie of property or ~us:ness, or relinquishment ef emp?oyme~t
at form~r dO'»iC~i@, ~c;riiOV3~ of fan,ily to ne~.v domicile, purchase of home, etc.} ~
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~U REG~R
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~tfRK C~°CU1T C,0$RT L
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~ 1 FURTHER CERTIFY that 1 will comply with a!i other requirements of a legal resident of this State.
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~ I FURTHER CERTIFY that I hav~ no intention to return to
my former domicile, and I intend to rema~n in FORT
~~,cRCE, SAINT LUGE COUNTY, FLORIDA, permanently.
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S•,+vom to ard sub~c!ibed before me this . _ _ _ day of . ~ ~ _ . , 19
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ROGER POITRAS _ - - - _ i
_ CLERK CIRCUIT COURT Notary Pubiic ~
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' ~Y _ - - 1 - ~ .lGc( - _ _ _ _ _ D.C. My Commission expires - - - - - - - - ,
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" (To be executed in duplicate and original filed with Clerk Circuit Court, snd duplicate with Tax Assessor.)
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D~J~ f~h..i
RI~ 1~9 510 '
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