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Declaration oi Domicile and Citizenship ~
TO THE STATE AND COUNTY TAX ASSESSOR. 235~36
:~1. LUCIE COUNIY, FIORICA: ~
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This is rny declaralion of Domicile and Citizenship in tiie Stale of Florida that I am fi~ing this day in accordance and
~n conformity with Chapter 222, Section 222.17, Florida Statutes.
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I was formerly a legal resident of -----~~'--.-`s~~~~---_ --1Y~~ t c~ -
(Ci ) State)
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and I resided at _ _ /SY_~~ ~aL ~ _ . _ However I have changed my domiCile
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(Street and Number)
to and am and have been a bona fide resident of the State of Florida since ---_~a~tL~_ day of
~~j , 19_?~_., a~d 1 reside at . ~~•n C~~
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1 Street and Number)
FORT PIERCE, SAINT LUCIE GOUNTY, FLORIDA
and this statement is to be taken as my declaration of citizenship, actual legal ~esidence and domicile in the State of Florida.
(Insert here a~y pertinent facts, such as sale ot property or business, or relinquishment of employrnent
at former domicile, removal of family to. new domicile, purchase of home, etc.)
~ ~ i~~.~~ ~~od ~ f LEO ANO RECORDEO
~ ~ i~.LUC1E 80UNTY FLA.
ROCER POITRAS
CIERK C:RtU1T COURt t~I
RECORD vER~~IED~e
II~CC 11 I I 2? AN'T2
~35'736
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I FURTHER CERTIFY fhat I will mmply with all other requirements of a legal resident of this State.
I FURTHER CERTIFY that 1 have no intention to return to my former domic,ile, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
1'+P~ ~ zi~~ / G~!/},!,[~..~J ~~GI~
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, .J. ~
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~ SwoTn to and subscribed before me this ~ day of ~ , 19~_~~ ~
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ROGER POITRAS •
CLERK CIRCUIT COURT Notary Public
gy ~ L-~S~ ~ D.C. My Commission expires
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~ (To be executed in duplicate and original filed with Clerk Circuit Cou~t, and duplicate with Tax Assessor.)
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