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Declaration ot Domicile and Citlzenshlp
TO THE STATE AND COUNTY TAX ASSESSOR, 22s444 `
Sl. LUCIE COUNTY, FLORIDA:
This is my declaration of Domicile and Citizenship in the State of Florida that 1 am filing this day in accordance a~d
~n conformity with Chapter 222, Section 222.17, Florida Statutes.
;
I was formerly a legal resident of _~1.re'.~1~-~L~-~ -
(Ciy) (State) ;
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and I resided at I_' ~ Nowever 1 have changed my domicrile #
(Street and Number)
to and am and have been a bona fide resident of the State of Florida since - _ day of
. 19~, and I ~eside at ~ '~~~~~2~ -~.l~-y- - - `
j
(Street and Number)
FORT PIER~E, SAINT LUCIE COUNTY, RORIDA
and this statement is to be taken as my declaration of citizenship, actual iegal residence and domicile in the State of Florida.
(Insert here any pertinent fads, 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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tICE9'AItD j
•T. IE CQU ;
OCER P01tRAa
CLEItK CNtC{ilT 4
RECO1l0 rEA~r~ED ~
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~ ~26444
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z 1 FURTHER CERTIFY that I 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 domicjle, and 1 intend to remain in FORT
~
~ PIERCE, SAINT IUCIE COUNTY, FLORIDA, permanently.
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~ G-al~fs
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~~'A (Name) ~B~ihP.eJ
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• (Address)
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~ Sworn to and subscribed before me this ~ day of ~Y~~Aiul~ , 19
ROG~ POITRAS
~ ~it ti~ COt~T Notary Pubiic
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By ~~~tv D.C. My Commission expires
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(To b~ ~xecuNd in dupticats and ori~insl filed wilh Ct~rk qrcuit Court, and dupliut~ with Tax Assessor.)
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