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Declaration ot Domici{e and Citi~eenship
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TO THE STATE AND COUNTY TAX ASSESSOR, y
2?352'74 ~
S7. LUCIE COUNTY, FLORIDA: I
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This is my declaration of Dornicile and Citizenship in the State of Florida that I am filing this day in accordance and
~n conformity with Chapter 222, Seciion 222.17, Florida Statutes.
I was formerly a legal resident of _ i.l_~~et,,LL a a~~ _ -
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(Ciry) (State)
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and I resided at _~~.l~•_~_~~/'~ 3~!? However 1 have cha~ged my domic.ile
(Street and Number) ~ :
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ro and am and have been a bona fide resident of the State of Florida since Z~ day of ;
i
•',~'~j !
-~~i.Gl_ . 19~11 and I reside at~~L~~~.!
(Street a Number) ;
FORT PIERCE, SAINT LUCIE COUNTY, FlORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile i~ the State of Florida.
(I~sert here any pertinent facts, such as sale of property or business, or relinquishment of employment
at. former domicite, removal of family to new domicile, purchase of home, etc.)
, ~t/G{ i~-~ -
C~`?~~ S~ ~ P Y i~~ ~
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fILE~ ANO RECOROE9 ~
ST.lUC1E COUNTY FIA.
ROCER POITRAS
CIERK CtRCU1T COURT ~
RECORD VE~iIFiEO
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I 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 retur~ to my former domiGle, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FIORIDA, permanently. ;
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~ Sworn to and subatribed before me this day of -(d~-~ , 19~L
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ROGER POIT~/~?3
~ CLERK CIRCt~14'~COURT Notary Public -
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~ By - D.C. My Commission expires _
(To be executed in duplicate and original filed with Clerk Circuit Court, and duplicate with Tax Assessor.) !
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