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Declaration ot Domicile and Citizen5fl~p 235515
TO THE STATE AND COUNTY TAX ASSESSOR, _
Sl. lUCIE COUNTY, FIORIDA:
This is my decla~ation of nomicile and Citizenship in the State of Florida tFiat I am filing this day in accordance and
~n conformity with Chapter 222, Seclio~ 222.1'!, Florida Statutes.
I was formerly a legal resident of . . ~~1_0~_ ~ A
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~C;ty~ (State)
and I resided at _ Rrp_~!~_.._PRIoR__ ~J9X_~ /f~.f/.v~_,Ft~~"~__ However 1 have changed my domiCile
(Street and Number)
to and am and have been a bona fide resident of ihe Stafe of Florida since T~tG ~._-1-__-_ day of
- - 19~~, and I reside at •?~O~__ ~AMA~I.~i/~ ~[1 L
(Street and Number)
FORT PIERCE, SAINT LUCIE C~UNTY, FtORIDA ~
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.)
~ ~~1t~IQ l~~ L°l~/GO~'.~ti >ii. ~G~foo L
F lE0 ANO RECORDE~
s. S~• LUCIE COUNTY FIA. ,
ROCE~ ~OITRAS y
CIERK C~~CUIT COURT ~
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Auc t6 i oe PH'7Z ~
235515 ~ '
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I FURTHER CERTIFY that I will comply with all other requirements of a lega) 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. .
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' '~•i:: • ,L~ -
' - ~ ~ • (Name) .
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~ • ;''•••.....•~''r . (Address) .
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Sworn to and subscribed before me this day of ~'~`'v`" , 19.~~
- ~
ROGER POtTRAS ~ ;
RK CIRCUIT COURT Notary Public ~
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By Q=~~_1~ D.C. My Commission expires -
(To be executed in duplicate and original filed with Clerk Circuit Court, and dupliwte wilh Tax Assessor.)
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