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Declaration ot Domicile and Citizensh~p
TO THE STATE ANU COUNTY TAX ASSESSOR, 2~~2
51. IUCIE COUNTY, FLORIDA:
rhis is my declaration of Oomicile and Citizensh~p in the State of Florida that 1 am filing this day in accordance and
~n conformity with Chapter 222, Section 222.17, Ftorida Statutes.
1 was formerly a legal residem of t~,}~~ - "~`-~-V
- (Ciry) (State)
and I resided at _ ~7J J~-- . However I have changed my domicile
- (Street and Number) ~
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1o and am and have been a bona fide resident of the State of Florida since cJ"jQ/~f~` _3._ y ~
a
- - - _ _ , 19?~ - , and I reside at - - -~jQ~' ~/m uQbl. - - -
(Street and Number)
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 Ftorida.
(Insert here any pertinent facts, such as sale ot properry or business, or retinquishment of employment
at fo~mer domicile, removal of family to new domicile, purchase of home, etc.)
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0 AftO REC{~~
~~UCIE COWMTY flA. ~
O~E~ POITMS ~
a~ERK C~~CUIT OOIIRt C
RECORO VER~fIEO
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~ I FURTHER CERTIFY that 1 will comply with all other requirements of a legal resident of this State. ~
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~ I FURTHER CERTIFY that I have no intention to return to my former domiCile, and I intend to remain in FORT ~
~ PiER E SAINT LUCIE COUNTY FLORIUA rmanentl . ~
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s~ ~ . : i; r~f~. ~i~d~~dSLM~~/t[+v i
Name)
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' .•~`Sin~rnt3~and subscribed before me this day of .
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e~' ROGER POITRAS ~
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_ K CIRCUIT COURT Notary Public
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gy D.C. My Commission expires ~
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(To be execut~d in duplicate snd originsl filed with Ct~irk Circuit Covrt, snd duplicats with Tax Assessor.) ~
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~ aoo~20O P~GE~V45 ~
No. 13 q
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