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Decl~ration ot Domicile and Citisenship }
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TO THE STATE AND COUNTY TAX ASSESSOR, ~
Sl, IUCIE COUNTY, FLORIDA: Il~~va~V `U ~
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This is my declaration of Oomicile and Citize~ship in the State of Florida that I am filing this day in acco~dance and
~n conformity with Chapter ~22, Section 222.17, Florida Statutes.
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t was formerly a legal resident of ^
(City) ( ate)
and I resided at 0~T`'`~ However 1 have changed my domicile
(Street and Numbe~)
to and am and have been a bona fide resident of the State of Florida since ___~v~ j~,~ _ day of
- 19---, and I reside at d 3 3
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
and this statement is to be taken as my declaration of citi=e~ship, adual legal residence and domicile in the State of Ho~ida.
(Insert here any pertinent fads, such as sale of property or busi~ess, or relinquishment of employment
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at former domicile, removal of family to new domicile, purchase of home, etc.)
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t~~L~1C1E COUNtY fLA.
ROCER FO~TRAf
CIERK C1P.CU1T C T
AECORD YEF~FIEO
M~It I~ ~0 33 AM'7Z
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~ 1 FURTHER CERTIFY that 1 will aomply with all other requirementa of a leyal resident of this State. ~
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~ I FURTHER CERTIFIf that I have no intention to return to my former domitile, and I intend to ~emain in FORT
~ PiERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. ~
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Sworn to and subscribed before me this ~ day of , 19
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~ ROGER POITRAS
~ CLFRK CIRCUIT COURT Notary Public
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By D.C. My Gommission expires
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~ Ro b~ ~x~cut~d in dupliut~ and oripinal fil~d witl~ CIKk Cirwh Court, and duplirah wNh Tax Ass~ssor.)
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