HomeMy WebLinkAbout0736 ;
~
,
z
Declaration ot Domicil~ and Citizenship 233 `
31S '
;
TO THE STATE AND COUNTY TAX ASSESSOR,
Sl. LUCIE ~OUNTY, FIORIDA:
This is my declaration of Domicile and Citizenship in the State of Florida that 1 am fili~g this day in accordance and
in conformity with Chapter 222, Section 222.17, Fforida Statutes.
~
~ If
I was formerly a legal resident of _--~,1~ _ -
(Ciry) (State)
and 1 resided at ~_4_ ~K1~~ ~i't~ However 1 have changed my domitile
(St~eet and Number)
~ i
to and am and have been a bona fide resident of the State of Florida since _ v~Q__-______ day of ~
. - - 19~~, and I ~eside at ~ ° G~' , -
(Str t and Number)
1
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 Florida. ~
(tnsert he~e 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.)
~
L,inc~2~c~ a
- ~333~5
. r~ G~x~~
. s~~E RE ~
_ zu~ ~ 7~~ Rf
OAO
YER
F~p~
C~ ~C~9~
•~t. I~1 1 SO PH •T1 -
~
3
~ ~
~ ~
f
~
' i
t
~ 1 FURTHER CERTIFY that 1 will oomply with all other requirements of a(ega) resident of this State. ~
~ - ~
~
I FURTHER CERTIFY that I have no intention to return to my former domi~ile, and I intend to remain in FORT ;
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. €
. + . ;
~~~~~uN~~~~~~ 3
~`'`~~`VM~ CO~, (Name) ~
~ ~
~ ~ p -
" ` ''4~ /•~~d CLCu~ G[~t.e~
~ ~ ; , a: .
, (Addres ~Q~~"~-
~ ? .
~ ~ i1~ 1 • ~ ~.~4,, -
?
~iyGC/~~ii~A ~~h~d subscribed before me this ~ day of , 19 ~Z
.
~.~N`~ 1
ROGER POITRAS ~
CLERI( CIRCUIT COURT Notary Public ~
B ~k~-~O.C. M Commission ex ires ~
y , , y p ~
~ ~
~
(To be sxecuted in duplicaM and ori~inal ~iled with Cl~ric Circuit Court, snd duplicate with Tax Assessor.)
DO(M ~ ~
No. 13 A .
° .
~ ~ x
~ .
_