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Declaration ot Domicile and Cttizenship
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TO THE STATE AND COUNTY TAX ASSESSOR, '
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Sl. LUCIE COUNTY, FLORIDA: '
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This is my declaration of Domicile and Citizenship in the State of Florida that I am filing this day in accordance and
~n conformity with Chapter 222, Section 222.17, Florida Statutes.
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I was formerly a legal resident of . _ _ _ _ _ . _ -
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and I resided at _ o_~__ y° r a _ . Howeve~ 1 have changed my domiCile
(Streat and Numbe~)
to and am and have been a bona fide resident of the State of Florida since C' _ day of
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_ _ 19--_ , and I reside at ~!'~'t~~LQ~V~°-. ~ i
(Street and umber)
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA .
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 relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
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224512
~ ST~II
CIE COUNTY ~A, - /
ROCER POITRAS
F CLENR C~F.~U1T COURT
I RE('ORD YFFIFIED..,~,~
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! F~e 18 10 4s AM '11
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~ 1 FURTHER CERTIFIf thaf 1 will comply with all other requiremenis of a legal resident of this State.
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~ t FURTHER CERTIFY that 1 have no intention to return to my former domicule, and I intend to remain in FORT
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~ PIERCE, SAIt~'f lllCi~ C4UNTY, FLORIDA, permanently.
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Swom to and subxribed before me this _ day of ~ ~ , 19
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ROGER POITRAS _
~ CiRCUIT URT Notary Public
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By D.C. My ~ommission expires
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_ (To b~ exscuted in dupliute and original ~iled witb Cbrk Grcuit Court, and dupliuf! witb Tax Ass~ssor.)
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