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DeClaration of Domicile and Citizenship
TO TNE STATE AND COUNTY TAX ASSESSOR, •
Sl. lUC1E COUNTY, FIORIDA: 2`~,6128
This is my declaration of Uamicile and Citizenship in the State of Florida that I am filing this day in actordance and
in conformity with Chapter 222, Section 222.17, Florida Statutes.
1 was formerly a tegal resident of .____~~_~_C~
LA~~_~1_~l~r~CZ3'_ _
(City) (State)
and I ~esided at J~~ Yi~/ls~~L~~A~ However I have changed my domiti~e
(Street and Number)
to and am and have been a bona fide resident of the State of Florida si~ce ___i'(~~~L~~~_.____-_-___._ day of
- - 19?.~ and 1 reside at /iis~.~ ~ir's~c/~l~'~/ ~
(Str t and Number) ~
~I~~~T S~L.vt~.~ ?
FORT PIERCE, SAINY IUCIE COUNTY, KORIDA '
and this statement is to be taken as my declaration of citizenship, actual legal residence a~d domicile in the State of Florida.
(Insert here any pertinent facts, s~ch as sale of property or business, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
` /tii~'!i?~o'!~~ ,fioAV~.~ ~or .I>r?.~= Idi,a~.~js ~Ii?~ ,aEc i..ri.v.~
'~E~i~'1i/A'rFI~T ~~"t/~Ifi~'T ' - ' ~
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F LEO AMp RECWt
i~ RIOM~.IE POt~=~
RECORO VERIFIEp C~Rt ~
N~t 1~ II 3~ ~M'1t
' 22~1.28
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~ 1 FURTHER CERTIFY that I will comply with all other requirements of a legal resident of fhis State.
~ 1 FURTHER CERTIFY that I have no intention to return to my former domiGile, and I intend to remain in FORT
~
~ PIERCE, SAINT lUCiE COUNTY, FLORIDA, permanently. , ~
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f~ . 4.'4tribed before me this da of v/~
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K ROGER POITRAS
CLERK CIRCUR COURT Notary Public
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By D.C. My Commission expires
~ (To be ~xecut~d in dupliute snd oripins{ ~iled with Cl~rlc Grcuit Courf, and duplics» with Tax Assestor.)
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