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Declaration ot Domic~le and Citiz~nship
TO THE STATE ~ND COUNTY.TAX ASSESSOR,
Si. lUC1E COUNTY, FIORIDA:
This is my declaration oi Dornicile and Citizensl~ip in the State of Florida that I am filing ihis day in accordance and
~n conformity with Chapter 222, Section 222.17, Florida Statutes.
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1 was fo~merl a 1 at re i ent - -1~ L1K/
y eg s d of _ _ ~ _ _ _ _
(City) (State
and I ~esided at • ~I_ However ! have chan ed m domi~ile
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(Sireet and . Number) ~ • ~
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to and am and h3ve been a bona fide resident of the State of Florida since _ ' _ day of '
~ -~~C~-------- 19~ and 1 ~eside at - - ~
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(Street and mber)
FORT PIERCE, SAINT LUClE COUNTY, FLORIDA '
and this statement is to be taken as my declaration of citizenship, actual lec~al residence and domicile in the State of Florida.
(Inserl 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.)
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Fi~EO ~NO R~coROeo t
St.IUCIE C011NTY FLA. ~
' ROCER FOtTRAS ~d(/1
~ CLERK CIRCUIT COURT
RECOR~J VEP'FIC~ U
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I FURTHER CERTIFY that 1 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 domic,ile, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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. . (Name) G 6 bD~'S
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~ Swo~n''to and subscribed before me this day of , 19! ~ t
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4: - _ J
ROGER POITRAS _
~ CLERK CIRCUIT COURT Notary Public
gy ' m C ~ 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 Asseswr.) ;
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