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Decfaration ot Domicile and Citi=~n~hip
TO TtIE STATE AND COUNTY TAX ASSESSOR, 2358f 5
~ i . tUC1E COUNTY, FLORIDA:
Tliis is my declaration of Domicile and Citizenship in the State of Florida that I am tiling this day in accordance and
~n con(or~nity with Chaptcr 222, Section 222.17, Florida Statutes.
I was formerly a lega) resideM of ~~/Q----- - ~d_E_tL!`y~~-- -
~C~~,~ (State)
and 1 resided at _O~ 7o__Q~_/~/___ f~/~7L[/_ ~~~1~ ~ o~l.~___ However I have changed my domiCile
(Street and Number)
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ro and am and have been a bona fide resident of the State of Fiorida since . ~1J_~-_`~_ •_~_~--T day of
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- - 19~, and I reside at ~~~Tii~F~'/4/-'~ U ~v - -
(Street and Number)
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. t
(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.) -
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1 FURTHER CERTIFY that I will comply with all other requirements of a legal resident of this State.
1 FURTHER CERTIFY that I have no intention to return to my former domi~ile, and I intend to remain in FORT
PlERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
,.::a.tri~ ;
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. ~ (Name)
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~ Sworn to ~and subscribed before me this °1 Z day of - , 19ZL'
ROGER POITRAS - -
CLERK CIRCUIT COURT Notary Public `
E3y ~L`~ D.C. My Commission expires
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- (To be executed in duplicate and original filed with Clerk Circuit Cowrt, and duplicate with Tax Assesso~.)
. , , sooK 205 ~~E 1~52
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