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Declaration ot Domicile a~d Citizenship
TO THE STATE AND COUNTY TAX ASSESSOR,
Sl. IUCIE COUNTY, FIORIDA: ~
This is my declaratian of Oomicile 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. ~
I was formerly a legal resident of ,v~- - - Grr+-IK'~ • --i~~~~" -
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. (City) ( a )
and 1 resided at i_I ~ f_~/r='~'~'~__- ~~'""e_'. However I have changed my domiCu~e
(Street and Number)
to and am and have been a bona fide resident of the State of~Fbrida since ~3 - - _ day of :
t
:
, 19__~ ~and I reside at _ _ ~ ~ ~ _ ~ - - _ ' -
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, ftORIDA `
and this s?atement is to be taken as my declaration of citizenship, actual legal residence a~d domicile in the State of Florida.
(Insert here any pertinent fatts, such as sale of property or business, or relinquishment of employment R
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 lega) resident of this State.
I FURTHER CERTIFY that 1 have no intention to return to my former domiule, and 1 intend to remain in FORT
~IERCE, SAINT LUCIE COUNTY, FIORIDA, permanently_ ~
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~ (Name) ~p lh b0.12 d~ C 12.
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(Address)
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~ Sworn to and subscribed before me this day of _ , 19~
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~ ROGER POITRAS .u;k~';'a:.,'s - •
~ CLERK CIRCUIT COURT Notary Public ~
~ _~~?!L , ~ ,FMy Commission expires
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(To bs executed in duplicate and originsl ~ilsd with [le.k Grcuit Court. and duolicsts with Tax Assessor.)
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