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Oeclaration of Domiclle and Citlsenship
TO TNE STATE AND COUNTY TAX ASSESSOR,
57. LUCIE COUNTY, FLORIDA:
This is my decla~ation of Domicile and Citizensh~p in the State of Florida that 1 am filing this day in accordance and
~n conformity with Chaptzr 222, Section 222.17, Florida Statutes. ;
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I was formerly a legal resident of . .~1 ' _ - - • ~
(Ciry) - ~ (Sta
and I resided at _G~~-----~~L~~ ~ Howeve~ I have changed my domiCi~e
(Street and Number)
to and am and have been a bona fide ~esident of the State of Florida since day of
~ 3 c:. - `
19 and 1 reside at • ~ _ ~
t t and Number) ;
FORT PIERCE, SAlNT I.UCIE COUNTY, RORIDA
and this statement is to be take~ as my declaration of citizenship, actual lega) 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 comply with all other requirements of a leyal resident of this State.
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a 1 FURTHER CERTIFY that I have no intention to return to my former domiCile, and I intend to remain in fORT
~ PIERCE, SAIf~j.1,uC1E COUNTY, FLORIDA, permanently_ ~
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3 Sworn to and suburibed before me this /y day of - , 19~~
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ROGER POlTRAS ~
~ CLERK CIRCUIT COURT Notary Public
By ~ D.C. My Commission expires
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(To be ~xecuhd in dupliute and oriyinal filed with Clt~lc Grwit Court, and duplicat~ with Tax Assessor.)
= No. 13A 63RK~JJ F?;C[~~V5