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Declaratio~ ot Domicile and Citizenship
TO THE STATE AND COUNTY TAX ASSESSOR,
2~5403
Sl. lUC1E COUNTY, fIORIDA: ~
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, Ftorida Statutes.
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I was formerly a legal resident of _ _
- _ ,
(City (State)
and I ~esided at _ ~ _ _ _ . However 1 have changed my domici~e ~
(Street a Number) ~
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to and am and have been a bona fide resident of the State of Florida since ~tG~ day of
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- Q11- C',1L. - - - - - , 192~, and I reside at \„1~2J Q•c~v -
(Street and Number) •~t. ..~,~itC.~,
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FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and dcmicile 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 ~ew domicile, purchase of home, etc.)
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tFlLEO AND•REGDRDSp
~'t:lUCtE CO~UILTK ~11A.
~tOCER POfT.RYIs
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OLERK CIROUIt .QtWI~ 'ryl~
Rf'CORf VER?fl£0.~~
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~ I FURTHER CERTIFY that 1 will comply with all other requi~ements of a legal resident of this State. -
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~ I FURTHER CERTIFY that I have no intention to return to my former domic,ile, and ! intend to remain in FORT
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` PIERCE, ~~l~T LUCIE COUNTY, FLORIDA, permanently.
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Sworn to and subscribed before me this day of 4~~ , 19 7-~. ~
:r
°f ROC~ER POITRAS ~
y CLERK CIRCUIT COURT Notary Public ~
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gy ~ua~ D.C. My Commission expires j
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(To b~ txecuted in dupliute snd oripinal filsd with Cl~rk Circuit Court, snd duplicat~ with Tax Assessor.)
~ ~~0 ~i~90 ~
~ No. 13 A
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