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Deciaration ot Oomicile and Citizenship
Tp THE STATE AND COUNTY TAX ASSESSOR,
51. LUCIE COUNTY, F~oR~oA. 222962
This ~s my dedaration of Domicile and Citizenship in the State of Florida that ! am fil~ng this day in accordance and
~n cunformity with Chapte~ ~22, Section 222.17, Florida Statutes.
I was formerty a leyai resident of ~ Ol~ ~!1~~~~11V. _ ~1 i
(Ciy) (State) E
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C~ Pe'e. i
and I resided at ~ e1, ~ ~ - \ _ ~ _ ~ _ _ _ . However 1 have changed my domiGi~e k
(Street and Numbe~)
ro and em and have been a 6ona fide resident of the State of Florida since V~~N ~-1 _ 1_\_ . 1~ _ day of
, 19~~.. and I reside at Q~4__ e - T'1--~ 'C..
'~tree~ ~n umber)
FORT PIERCE, SAINT LUCIE COUf~sY, 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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~ 1 FURTHER CERTIFY that I will com I with all other r eg
~ p y equirements of a 1 al resident of this State.
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~ I FURTHER CERTIFY that 1 have no intention to ~et~rn to my forme~ domiCile, and I intend to remain in FORT
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~ PIERCE, SAINT Lt~1E COUNTY, FIORIDA, permanenNy_ ~
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= Sworn to and subscribed before me this _ day of --I~~~ , 19.Z11
ROGER POITRAS
- CLFitK CIRCUIT COURT Notary Public ~
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BY ( D.C. My Commission expires ~
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~ (To be ~xecuted in duplicats and oripinal filed with Cl~rk Grcuit Court, and duplicats witb Tax Ass~ssor.) i
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