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Declaration ot Domicile and Citizenship
10 THE STATE AND COUNTY TAX ASSESSOR,
Si. IUCIE COUNTY, fLORIDA: ~~SBVO
This ~s n~y decla~ation of Uomicile and Citizenship in the State of Flarida that I am fil~ng this day in accardance and
~n conformisy with Cha~~ter 222, Scction 222.17, Floridu Slatutes.
I was formerly a legal resident of . _ . _ n~ ~l~~~ _ _ - ---_-~1~.~~4-i-
(City) (State)
Y___ j O! However I have changed my domiCile
and 1 resided at 3 ~-Q ` h~_ •
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(St~eet and Numbe~)
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to and am and have been a bona fide resident of the State of Florida since _,__Y day of
~L~-~-~--- 19_~~nd I reside at ~Y'~~C~_~ L-~' o~' ST j.._~Ll~°+------_ i
3ensen 13.Qcu~ (Street and Number) ~T (p/~ ~
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
and this statement is to be taken as my declaration of citizenship, actual lega) residence and domicile in the State of Florida.
(Insert here any pertinent facts, s~ch as sale of property or busi~~ss, or relinquishme~t of employment _
at former domicile, removal of family to new domicile, purchase of home, etc.)
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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 i~te~d to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently_
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Sworn to and subscribed before me this day of , 19~~
ROGER POITRAS . -
,F CtERK CIRCUIT COURT Notary Public
E3y _ ~ O.C. My Commission expires
(To be executed in duplicafe and origi~al filed with Clerk Circuit Court, and duplicate with Tax Assessor.) ~
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