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Decla~ation ot DomiCile and Citisenship ~
2z5193
TO THE STATE AND COUIVTY TAX ASSESSOR,
Sl. IUCIE COUNTY, FLORIDA:
This is my declaration of Domicile and Citizenship in the State of Florida that I am filing this day in accordance and
in conformity with Chapter 222, Section 222.17, Florida Statutes.
I was formerly a tegal resident of _ Frankl Ae~l Ha~p~hire
(City) (State)
and 1 resided at 38 __peabOdy P~BC@ He~„~ever I have changed my domiCile
(St~eet and Number)
to and am and have been a bona fide resident of the State of Florida since _15th___- day of
October , ~q 71, and i reside a~ 1707 Sunset Isle Road _
(Street and Number)
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, suth as sale of property or business, or relinquishment of employment +
at former domicile, removal of family to new domicile, purchase of home, etc.)
Establi~hing residence i~2J193
FILEO AMD RECORDE
ST. LUCIE COUNTY f~
R06ER POITpAS
i CLERK CIRCUIT ~OUAT
RECORD VERIFIEO~~
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= I FURTHER ~ERTIFY that 1 will comply with al) other ~equirementa of a lega) resident of this State.
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; 1 FURTHER CERTIFY that I have no intention to return to my former domicjle, and I intend to remain in FORT
~ PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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~~Sworn to and subscribed before me this 9th day of Y8TCh ~ 19 72
- ROGER POITRAS
LERK CIRCUIT OURT Notary Public
By " D.C. My Commission expires
= (To bs ~x~cut~d in dupliuM and oripinal fil~d with C{~rtc Urcuk Court, and dvpliut~ with Tax Ass~sior.)
800K ~?VO PACr ~
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