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Declaratio~ ot Domicile and Citisenship
TO THE STATE ANO COUNTY TAX ASSESSOR,
Sl. LUCIE COUNTY, FIORI~A: ~~~VJ
This is my declaration of Domicile and Citizenship in the State of Florida ihat 1 am filing this day in accorda~ce and
~n conformiry with Chapter 222, Section 222.17, Florida Statutes. /
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I was formerly a legal resident of ~ . - - ~ --~-a~-~, - - - - - - - - - ~
State) 1
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and I resided at ' _ / , ! I=' . However I havechanged my domiG~le
~ Street and Number) ~
to and am and have been a bona fide resident f the State of Florida since ~ Q - day of
' - - , 19~1 , and I reside at _~~~'y- ---L!~lis~c~as~-~t`t- ~9 _ - -
~ (Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, FLORl~A
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 properry or business, or reli~quishment of employment
at former domicile, ~emoval of family to new domicile, purchase of home, etc.)
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~ + I FURTHER CERTIFY that I will camply with a!I other requirements of a legal resident of this State. ~
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~ I FURTHER CERTIFY that 1 have no intention tc ~eturn to my former domiGle, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently_
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- "?$wJl~ t4 end subscribed before me this day of -
ry
`'A
ROGER POITRAS -
CIRC T COURT Notary Public
gy _ D.C. My Commission expires
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(To bs sxecuted in duplicst~ and o~~insl ~il~d with Cl~rk Grcuit Cour1, and duplicsN with Tax Asstssor.)
tti a~19,9 ~1554
No. 13 A
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