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Declaration ot .Domictle a~d Citizenship
TO THE STATE AND COUNTY TAX ASSESSOR, 2`~B~Q
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51, lUC1E COUNTY, FIORIDA:
This is my decla~ation of Domicile and Citizenship in the State of Florida that 1 am filing this day in accordance and
~n conformity with Chapter 222, Section 222.17, Florida Statutes.
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I was fo~merly a legal resident of~E~ ~vt~ /Y O
(City) (State) ~
and I ~esided at ~J , VP~A~C ~ACt ~~„~e„~ I have changed my domicile
(Street and Number)
to and am and have been a bona fide resident of the State of Florida since ~~'~L -3 - - day of
. 197 and I reside at ~~O ~R//?SAl[~
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, RORIOA
and this statement is to be taken as my declaration of citizenship, actual fegal residence and domicile in the State of Horida.
(Insert here any pertineret facts, such as sale of property or business, or relinquishment of employment t
at former domicile, removal of family to new domicile, purchase of home, etc.) ~
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ROCER POITItAS
~ CLERK CIRCUIT COl1~T ~
j RECORD YERIFIEO~
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g 1 RIRTHER CERTIFY that I will comply with all other requireme~b of e(e~a{ resident of this State.
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~ I FURTHER CERTIFY that I have no intention to retum to my former domiCile, and I intend to ~emain in FORT
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~ PIERCE, SAINT LUCtE COUNTY, FLORIDA, permanently.
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~ - j~~. t~~ ~iuribed before me this day of _ , 19~~!
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= ROGER POITRAS
CLERK CIRCUIT COURT Notary Public
By O.C. My Commission expires
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~ (To b~ ~x~evNd in dupliuM and ori~nal fif~d wilh Cf~eic CiKUif Courf, and d~plieat~ wkl+ Tax Assa~or.)
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