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Dectaration at Domicile and Citizen~hip
TO THE STATE AND COUNTY TAX ASSESSOR, 235894 ~
~l. LUCIE COUNTY, FLORtDA: ~
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This is my declaration of Domicile and Citizenship in the State of Florida that I crn fil~ng ti~is day in accordance and ~
~n conformity ~vith Chapter 222, Section 222.17, Florida Statutes.
I was formerly a legal resident of -t _C_G~^--------. l'~----
(City) (State)
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and I resideci at :1 However 1 have changed my domi~ile .
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(Street and Number)
to and am and heve been a bona fide resident of the State of Florida since ~~f_/~_~~_ -_-~.~_L~:-~--- day of
- 19---, and I ~eside at 1_.~_~_~~ ?~'vo ' ~?-t~ r/~t.• r
(Street and Number) 33~S-a
fORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
and this sfatement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Flarida. ,
(Insert here any pertinent facts, such as sale of property or business, or retinquishment of emptoyment ;
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at former domicile, removal of family to new domicile, purchase of home, etc.) ~
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• 3'~.L'IJCIE COtttPf7~.
~RdCFP POt'19t~;
ClERK C~.^.Ci11? C~ ~~N
RECORI~ vERtFtED~
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I FURTHER CERTIFY that i will comply with all other requirements of a(egal resident of this State. ,
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1 FURTHER CERTIFY that I have no intention to return to my former domiCile, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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, (Name)
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Swprn to and subscribed before me this day of ~ - , 19~1-~' #
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ROGER POITRAS ~ `
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C RK CIRCUIT COURT Notary Public ~
8y - D.C. My Commission expires ~
(To be executed in duplicate and original filed with Clerk Circuit Court, snd duplicate with Tax Assessor.) ~
BOOK ~O~ PAC~',292 ~
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