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TO THE STATE AN~ COUNTY TAX ASSESSOR, ~~24643 i
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51. IUCIE COUNTY, FLORIDA:
This is my declarotion of Domicile and Citizenship in the State of Florida that I am filing this day in accordance and
in conformiy with Chapter 222, Section 222.17, Florida Statutes.
1 was formerly a legal resident of ~ _ _ - .
(City) (State)
~nd 1 resided at ,4~ _ - _ - However 1 have changed my domic.i~e
(Street anci Number)
to and am and have been a bona fide resident of the State of Florida nc ___-~'Z day of
~ a~',~-------
- - . 15~LL_, and I reside at / f'.G . ~O ~ ~ ~Cl/7 1
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, RORtOA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Florida.
(Insert he~e any pertinent fads, such as sale of property or busi~ess, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
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f ILEO ANO RECp~ $
=T. WCIE COIIMTY
IIOCT~R POITIIA= -
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~ I FURTHER CERTIFY that I will oamply with all other requirernents of a le~al residant of this State.
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~ 1 FURTHER CERTIFY that 1 have ~o intention to ~etum to my former domitile, and 1 intend to remain in FORT i
~ PIERCE, SAINT LUCIE COUNTY, FLOR{DA, permanently. ~
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r 9arpen to and subscribed before me this ~j 9 day of ~ , 19
- ROGER POtTRAS
-x~ U~ERI( CIRCUIT COIJRT Notary Public
.
:~5 By u~-°-~ D.C. My ~ommission expires
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~ (To b~ ~x~cuNd in dupl&s1~ sed o?iqinal fil~d with C1Kk Cirwif Co~r/, aed dvplicat~ with Tax Aswaor.)
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