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Oeclaratio~ ot Domicile and Citizenship
TO THE STATE AND COUNTY TAX ASSESSOR,
Sl. LUCIE COUNTY. F~oR~oA- 2231'~3
This is my declaration of Oomicite and Citizenship in the State of Florida ihat 1 am filing this day in accordance and
~n conformity with Chapter 222, Section 222.17, Flo~ida Statutes.
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I was formerly a legal resident of _
(Ci ty) (State)
and 1 resided at .//9 _ Howeve~ I have chan ed m domiCile
- - 9 Y
(Street and Number)
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ro and am and have been a bona fide resident of the State of Ftorida since day of
l~- ~"'µ''~'4'~-' 19 ~O , and I reside at `~7`~d
- - - ~ - - - - (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 properiy or business, or retinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
jILEO ~?NC~ RECORDEO
sT. LUCIE COUNTY fLA.
ROC~~t f01TRAS
CIERR C'~;CU~T COURT ~1.~
RFCRRC Y~hIF!EO~~C-
; Fee 1 I`l 28 PH'~Z
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~ 2231~'3
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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 I have no intention to retum to my former domic,ile, and I intend to remain in FORT
~ PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. ~
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(Name)
~ ' ~ ~ /71il.P~r r_ . pa~f f~?r~ N
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• (Address)
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• Swor~lty ~td subxribed before me this day of - , 19~
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ROGER POITRAS
- CLERK Cf IT COURT Notary Public
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By D.C. My Commission expires ~
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~ (To be ~xecuted in dupliuM and original ~iled witb CI~Ac Grcuit Court, aed dupliuts with Tax Ass~ssor.)
60CX1~ PAGE~OOZ 4
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