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Oeclaration ot Domicile and Citizenship
TO THE STATE AND COUNTY TAX ASSESSOR. 2z4220
Sl. WCIE COUNTY, FIORI~A:
Th~s ~s my declaration of •Dom~cile and Citizensh~p in the Sta~e of Florida that I am fil~ng this day in eccordance and
~n conformity with Chapter 2?4, Section 222.17, Florida Statutes.
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1 was formerly a legal resident of - -
(City) (State)
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and 1 resided at ~ 2.~ _ B'~~~~ However 1 have changed my domi~ile ,
(Street and Number)
ro and am and have been a bona fide ~esident of the State of F~orida since ~O? - L/ day of
/~~~Y
, 19_7~ , and I reside at o~7~g- p. ~ ~c, ~-Aie~~~
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNtY, FLORIDA ~ r /4 •
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Florida.
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(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.)
=~LE9 ~MD REC ~EO
; T R~ERC
OiTRA= ?
~ CiERR CIRCUIT COWIT
IIECORO YERIFIEO..~...~~.
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S 22~~20
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~ I FURTHER CERTIFY that I will comply with all ofher requirements of a legal resident of this State. ,
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~ I FURTHER CERTIFY that I have no intention to return to my former domiGle, and I intend to ~emain in FORT
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~ PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. ~
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' Swo~n,t~ a~-subscribed before me this day of r~~fut~ r , 19
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ROGER POITRAS - i
= CLERK CIRCUIT C URT ' Notary Public
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By . ~i~lL~t - D.C. My Commission expires
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(To be sxecuted in duplicate and oriQi~sl fils~! with Cl~rk Grcuit Courf, :nd duplicate with Tax Assesso~.)
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