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Decla~atio~ ot Domicile and Citizenship
TO THE STATE AND COUNTY TAX ASSESSOR, ~
Si. LUCIE COUNTY, FIORIDA: ~24442 ;
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This is my declaration of Dom~cile and Citizenship in the State of Flo~ida that I am filing this day ~n accordance and
~n conformity with Chapter 222, Section 2?2.17, Florida Statutes.
I was formerly a legal res~dent of _ . _ . __~~'~~~~~6~0~ _ _ ,-('~~i6yA/
~C;ty~ (State) ~
33 ~ 3~ .C3~ oo~-S %a*.t/ Nowever I have chan ed m domicjle ~
~r.d I resided at . - - - - - - 9 Y
(St~eet and Number)
_f _ _ . .
ro and am and have been a bona fide resident of the State of Florida since day of
,3~..57 ~/~N/N65/O~ tj'/r ~
_ _ - , 19--- - , and I reside at - - - - - - - - -
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
and this statement is to be taken as my decla~ation of citizenship, actual legal residence and domicile in the State of Ftorida.
(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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Ct RKCC qCUIT C~~ ~ ~
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~ 1 FURTHER CE~tTIFY that I wil) comply with all othsr requirements of a legal resident of this State.
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~ 1 FURTHER CERTIFY that I have no intention to return to my former domi~ile, and 1 intend to remain in FORT
~ PiERCE, SAlNT LUCIE COUNTY, FIORIDA, permanently.
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ee t~ n M /yic D~ t~ $ a/! .
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Sworn to and subscribed before me this - day of . 19~~ i
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=f~ ROGER POITRAS _ i
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C CIRCUIT COURT Notary Public ~
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By D.C. My Commission expires t
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- (To be oxecuMd in duplicats and originsl filad with Cl~rk Grcuit Court, and dupliut~ with Tax Ass~ssor.) ;
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~0~1~ ~E2805
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