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Declaration ot Domicile and Citizensttip
TO THE STATE AND COUNTY TAX ASSESSOR. ~ 2~5266
Sl. LUCIE COUMY, FtOR1DA:
This is my declaration of Lbmicile and Citizenship in the Sta~e of Florida that 1 am filing this day in accordance and
~n conformity with Chapter 222, Section 222.17, Flo~ida Statutes. -
I was forme~l a le al resideM of ~~+.~c{: -
Y 9 - 2.~----- -
(City) (State)
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and 1 resided at ` _ Howeve~ I have changed my domiule
(Street a~d Number)
to and am and have been a bona fide resident of the State of Florida since day of
1
- - - 19_Z~, and 1 reside at ,1"..,L-_~L~~ ~ ~ ~ ~ ` ~.~C~~ ' - -
(Street and Number)
~
,
FORT PIERCE, SAIN? 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.
(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.) 1
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~~o-~-e-,~ Fi~EO ANO aECOR~Eo
, . ST. LUCIE COUNTY LA.
_ CIERR C RCUIT COURT m t
• . RECORO YERIFIEO~~
~ !~I 12 2~ PH'11
.
23.5266
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1 FURTHER CERTIFY that I 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 domiCule, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FIORIDA, permanently. ~
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(Name) ~ross co. ~ ~
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Swom to and subscribed before me this day of Sc~ , 192-.
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ROGER POITRAS • -
CLERK CIRCUIT C ~.J ' Notary Public
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By -_...z ~ D.C. My Commission expires
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(To be executed in duplicate and original filed with Clerk Circuit Court, and duplicate with Tax Assessor.) ~
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