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Declaration ot Domicile and Citizenship
TO THE STATE AND COUNTY TAX ASSESSOR, • •
Sl. LUCIE ~OUNTY, FIORIDA:
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This is my declaration of Domicile and Citizenship in the State of Florida that I am filing this day in accordance and ~
~n conformity with Chapter 222, Section 222.17, Florida Statutes.
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1 was formerly a legal residenYof ___~~~4~____.- _
(City) (State)
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and 1 resided at __1 fl ~ However 1 have changed my domiCile
~ (Sireet and Number)
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to and am and have been a bona fide resident of the State of flo~ida since _~L_ day of
L ~ ~
~ 19?L_, and I reside at - - _ ,
(Street a~d Number) 1
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FORT PIERCE, SAtNT LUCIE COUNTY, RORIDA
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 family to new domicile, purchase of home, etc.)
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?1.11CIE COilM~'~
' RQGER POITRII~
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~ I FURTHER CERTIFY that I wil) oomply with all other raquirements of a leqal 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_ GE E COUR
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~ ' (Name) i
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- ' '~~woi~ to bn~ subscribed before me this 7~ day of ~ p"'O~~ 19~L
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. •
- -
ROGER POITRAS
ClRC COURT Notary Public
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_ By ~ D.C. My Commission expires
~ (To ucscvhd in dupticat~ and o?i~insl fibd with Cbrk Grcuif Court, and duplicst~ with Tax Ass~ssor.)
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