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~eclaration ot Domicile and Citizenship
TO THE STATE AND COUNTY TAX ASSESSOR, • ,~ti 2D~O
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Sl. lUC1E COUNTY, FLORIDA:
This is my declaration of Domicile and Citizenship in the State of Florida that 1 am filing this day in accordance and
in conformity with Chapter 222, Sectian 222.17, Florida Statutes.
1 was formerly a legal resident of _L`~~~~-~!~ .5(~~/~ir a_ _
(City) (State)
and 1 resided at ___-_~t_~_~~.,~~~~G However I have changed my domiti~e
(St~eet and Number)
to and am and have been a bona fide resident of the State of Florida since _______~3~..~ - _ day of
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~ /~'s~!~ 19~ , and I reside at _ ~v ~ E. CAL /~'!0 5 ~ ,D~/(~~
~ (Street and Number)
fORT PIERCE, SAINT LUCIE COUNTY, RORIDA
and this statement is to be taken as my declaration of citizenship, actual legal reside~ce and domicile in the State of Florida.
(Insert here any pertinent facts, such as sale of property or business, or relinquishment of employment
at former domicile, removal of family to new domicite, purchase of home, etc.)
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i~t~}y~1E CO~M7~ ~
ROCEI~ POITItI?: s
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IlECO
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~ I RJRTHER CERTIFY that I will oomply with all other requiremenri of a leyal resident of this State. ~
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~ I FURTHER CERTIFY that I have no intention to return to my former domiGle, and I inten~ to remain in FORT ~
~ PIERCE, SAINT IUCIE COUNTY, FtORIDA, permanenNy. (
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- - ,~wp~~~p~ai~`~t~istribed before me this ~ day of , 19~L-
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ROC~ER POITRAS
j CLFJtK CIRCUIT• COURT Notary Public
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By ` ~ D.C. My Commission expires t
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- (To b~ ~xscut~d in duplicat~ and ori~i~al filed witb CINk Grwit Court, and duplicat~ with Tax Ass~tsor.) !
~ , 3A g~o ZOQ ~ 39?
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