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Decl~ration ot Domicile and Citizenship
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TO THE STATE AND COUNTY TAX ASSESSOR,
Sl. WCIE COUNTY, FIORIDA:
This is my deciaratio~ of Oomicile and Citizensh+p in the Sta~e of Flo~ida that 1 am fili~g this day in accordance and ~
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~n conformiy with Chapter 222, Section 222.1~, Florida Statutes. _
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I was formerly a legal resident of [ 4'~ ~~t~? ~'L - ~e Q
~C~~ (State)
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and 1 resided at _c~ ~'L~ e!-~~~'-' - However 1 have changed my domivle
i5treet and Number)
to and am and have been a bona fide resident of the State of fiorida since ~ - day of
vQnt./~~r , 19 2l and 1 reside at -S~_r Z_~_~ `F-R. ~`T'
(Street and Number)
FORT PiERCE, SAINT LUCIE COUNTY, fIORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicite in the State of Florida.
(Insert here any pertinent facts, such as sale of property or business, or relinquishment of employment
at former domicile, ~emova4 af famity to new domic+le, purchase of home, etc.)
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~ 1 fURl'HER CERTIFY tfiat 1 wiil comply with alt other requirements of a ieyai resident of this State.
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1 FURTHER CERTIFY that I have no intention to return to my former domic~le, and 1 inte~d to remain in FORT
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4 PIERCE, SAINY`LUCIE COUNTY, FLORIDA, permanently_
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Swom to and subscribed before me this .-_"2 ~ _ day of 6~=k-=•-!-~- , 19Lz-
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ROGER POITRAS '
CLERK ClRCU1T COURT Notary Public
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~r By ~ _ D.C. My Commission expires
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~i (To b~ ~xscut~d in duplicato and ori8inal fil~d with Cl~rk Ci~cuit Court, and duplicat~ with Tax Ass~ssor.)
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