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Declaration ot Don~icile a~d Citize~ship
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TO THE STATE AND COUNTY TAX ASSESSOR, 2253~1 .
51. IUCIE COUNTY, FlORIOA:
This ~s my declaration of Domicile and Citizenship in the State o' Florida that I am filing this day in atcordante and
in conformity with Chapter 222, Secfion 22~.17, Floride Statutes.
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I was formerly a legal resident of _ ~?_e~[~°!~°~!~V~~- -~~~L~~~----- ~
(City) (State) ~
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and 1 resided ar ~ ~~X _ 5-~-~----------- - - - ~ However 1 have changed my domi~ils ;
(Street and Number)
to and am and have been a bona fide resident of the Stats of Florida since ~KC~ day of 3
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, 19Z_/__, and 1 reside at fl0.~ ~~//~~C _ _ - _
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, (Street and Number)
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f 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, such as sale of property or business, or relinquishment of employment
at former domicile, removal of famify to new dom~cile, purchase of home, etc.)
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fILED ANO RECQRQ~
SL LUCIE CBUNTr FL
ROCEn FOITRAS
CIERK Ci~tCOtT CO
RFCnR~ V~='%tE
N~ 13 9 3? ~N'~2
~2253~1
~ 1 FURTNER CERTIFY that I will comply with al) other requirements of a legal reside~t of ihis State.
I FURTHER CERTIFY that I have no intention to return to my former domicjle, and I intend to remain in FORT
_ PIERCE, SAINT LUCIE COUNTY, FLORtDA, permanently.
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Swom to and subscribed before me this day of ~~2z~ , 19 ~
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ROGER POITRAS ~
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~=r ~lERK CiRCWT COURT Notary Public i
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BY D.C. My Commission expires ~
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~ (To b~ ~xecutad in duplicate snd original filed with Ci~?k Grcuit Court, and dupliuM with Tax Asssssor.) ~
~ bO~IC T.W i~Lf 1~ #
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No. 13 A '
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