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Declaration ot Domicile and Citizenship
TO THE STATE AND COUNTY TAX ASSESSOR. 2;~493
51. IUCIE COUNTY, FIORIDA:
This is my declaration of Domicile and Citizenship in the State of Florida that I am filing this day in accordance and
~n conformity yrith Chapter 222, Section 222_17, Flo~ida Statutes.
I was formerly a legal resident of~ ~~r_~iv~ ' ..i' - !~~'J -
~ ty~ (State
and 1 resided at ~v~__LI,~_ ~ G~ . Howeve~ 1 have changed my domiCile
C~~~~L~~ (Street and Number) i
to and am and have been a bona fide resident of the State of Florida since _ day of
,?:yC~(~ 19~`~ and I reside at~'~=~.~-_ _.~-~-4~ ~i~
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
and this statement is to be taken as my declaration of citiienship, 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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~ I FURTHER CERTIFY that 1 will comply with all other requirements of a legal resident of this State.
~ I FURTHER CERTIFY that I have no intention to return to my former domiGle, and I intend to remain in FORT
~
~ PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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~ (Name)
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(Address) - -
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Sworn to and subscribed before me this f ` 19 . ~
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ROGER POITRAS
> CLERK CIRCUIT COURT ary Public ~ ~ -
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.~.:...1 YJ~tiG SiAI! t~~ A~:1~R6E
~ ~ ' 'ai~.:~SaiG:t Exr;11E~' 7, 19T;G
By D.C. My Commission e~K
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~ (To be sxecurod in dupliute and ori~insl filed with G~rk Grcuit Court, and dupliute with Tax Ass~s~or.)
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Plo. 13 A :
~ aooK 200 ~c~27'36
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