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DeClaration ot Dornicile and Citisenship
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TO THE STATE AND COUNTY TAX ASSESSOR, , 33;3fl
Sy . LUCIE COUNTY, FLORIDA
This is my declaration of Domicile and Citizenship in the State of Florida that I am
filing this day in accordance and
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:n conformity with Chapter 222, Section 222.17, Florida Statutes.
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t was formerly a legal resident of ~-R ~_R~ ~-~j - - - - ~~`~"'-i-r , -
t N ~ (State)
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and 1 resided at t Q t~ V ~~_.~LL~~U.-~ Y~~. C~ Nowever 1 have changed my domicjle
(Street and Number)
to and am and have been a bona fide resident of the State of Florida since - day of
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. ~e ~ . 19_~ and I ~eside at ~ - v~,~~ ;
(Street and Number)
S v~?~c~ ~ U R t S i. V~~, 1 E
FORT PIERCE, SAINT LUC1E COUNTY, FLORIDA ~
ard this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Florida.
flnsert 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.)
fIlEO ~K~ NECORDEO
ST.IUC~i ~OUN~Y FLA.
ROG_~ F'+:T~AS
C! EKI: L?!T COURT J?~L ~
Rc~~a~ VE~ , -'--_~L'
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~ I FURTHER CERTIFY that I will comply with all other requirements of a leyal resident of this State.
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~ I FURTHER CERTIFY that 1 have no intention to return to my former domic,ile, and I intend to remain in FORT
~ PIERCE, SAINT LUCIE COUNTY, FIORIDA, permanentlY- ~~R?•Sr~ F-
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Sworn•to end subscribed before me this day of ~~~f . 19~ ~
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- - ROGER POITRAS - -
C~ CIRCUIT C. RT Notary Public
gy I " D.C. My Commission expires
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(To bs executed in dupticat~ and ori~inal ~iled with Cltrk Grcuit Cou~t, and duplicat~ with Tsx Ass~ssor.)
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