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DeCiaration ot DomiCile and Citizenship
TO THE STATE AND COUNTY TAx ASSESSOR. ~25~14
51. LUCIE COUNTY, FIORIDA:
This is my declaration of Domicile and Citizenship in the State of Florida that I am filing this day i~ accordance and
in conformity with Chapte~ 222, Section 222.17, Flotida Statutes.
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1 was formerly a legal resident of ~a~~s.r.t~ ~ ~
(City) (State)
and 1 resided at ~Q~_~'1!!a~t~ . G~ _ . However 1 have changed my domicile
(Sfreet and Number) ~
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b and am and have been a bona fide resident of the State of Flo~ida since .__.~s,~7~ _~_~~Q~____ day of
. 19--, and I reside at 12Q-f.~ ~o••Y~ 11~~.eA~J~'Q
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, FtORIDA ~
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Flo~ida.
(Insert here any pertinent facts, such as sale of property or business, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.) 2~31~
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~ ROCER POITU~
RECORO YER~ F~IEO
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1 FURTHER CERTIFY that I will comply witfi all other requireme~ts of a leya) resident of this State.
I FURTHER CERTIFY that I have ~o intention to retur~ to my former domicjle, and I intend to remain in FORT
PIERCE, SAINT U.'CIE COUNTY, FIORIDA, permanently.
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S~~' . (Name) ~„w~P
_ ~ • ,~I.ylP,ej .~1.
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. w _ ~ ~ _ . /70 i~~y~
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` Swo~n tp.tlT~nd ste~i~cribed before me ihis ~G day of ~~'•~G~~~~~~ , 19
.
ROGER POITRAS _
Ci.ERK CIRCUIT COU T Notary Public '
By ~ D.C. My Commission expires
(To bs ~xecut~d in duplicah and ori~inal fil~d wita q~uk Ci~wit Court, snd dupliut~ with Tax Assassor.)
N~ 13 A
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