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Declaration ot Domiclle and Citizenship
TO THE STATE ANU CC~UNTY TAX ASSESSOR,
223032
Sl. IUCIE COUNTY, FLORIDA:
Th~s ~s my declaration of Dom~cile and Cieizenship ~n the State of Florida that I am fil~ng this day in accordance and
~n conformity with Chapter 222, Section 222.17, Florida Statutes.
1 was formerly a lega) resident of ~ 1~ Y~i F`-i
~C;~yj (State)
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and I resided at ~l ~i~/7~~~Lf _ However 1 have changed my domici~e i
(Street and Number)
io and am and have been a bona fide resident of the State of Florida since ~ _ day ot
, 19_ , and I reside at 1°L-~
(Street and Number)
. FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
and this statement is to be taken as my declaration of c~tizenship, actual lega) residence and domicile in the State of Flo~ida.
(Insert here any pertinent facts, such as sale of property o~ business, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
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i1LE0 ~N^ REC4RDES
St~ lUC1C %~UNtY F1A.
ROCE~~ r'J?TRAS ~
CLERK C~ ~GUIT COURT
R~COR(' V~":?'ED„~
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~ I FURTHER CERTIFY that I will comply with all other requirements of a legal resident of this State. ;
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~ I FURTHER CERTIFY that 1 have no intention to return to my former dom~c,ile, and I intend to remain in FORT ~
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PlERCE, SAIMT' L~~lE COUNTY, FLORIDA, permanently.
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- Swom to and subscribed before me this day of `-~~C~t~ 19 ~1!
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ROGER POITRAS
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CLEItK CIRCUIT COURT / Notary Public
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BY -a~1[ G~~L~-~ - D.C. My Commission expires `
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(To bs ~xecut~d in duplicata snd original filed wHh CI~?Ic Ci~cuit Court, and duplicats with Tax Ass~ssor.)
„ a oK 199 ~?~E .795
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