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Declaration ot Domicile and Citizenship
TO TNE STAT[ AND COUNTY TAX ASSESSOR, ~ ~36~~0
Si IUCIE COUNTY, FLORIDA:
This is my declaration of Domic~le and Citizensh~p in the State of Floric~a that 1 am filing this day in accordance and
~n conformity with Cha~ter 222, Section ?22.17, Florida Statutes.
' G/ -
1 was formerly a legal resident of ~~~~~~~~~Cf~`_----------- -
~C~ty~ (State)
and I resided at _~J`LA~~~!1-~i~'- . . Fiowever I have changed my domiCile
J (Street and Number)
to and am and have been a bona fide resident of the State of Florida since day of
- - 19_ and I reside at _ /~/_1 ~i~~ =iL~q n o• ~ i
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(Street and Number)
FORT PIERCE, SAlNT LUCIE COUNTY, FLORIDA
and this statement is to be taken as my dectaration of citizenship, actual legal residence a~d 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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Applying ~ for Homestead
Entering children in school :
FILED AfrO RECQRDEO
~ C~`v ` ST. LUC?E COUNTr F~~, '
~ ~ ROGE%• ~~;;R~s ~
C! E~K C:'tCU~T COURT
PFCCF~ y_:.•L-~~~~'ff!
~ ~ ~ 1g i i s~ AM '71
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1 FURTHER CERTIFY that I 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 domi4le, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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Swo~n to and subscribed before me this _ day of - ~ 19~.f
ROGER POITRAS _ _ - -
, CIERK CIRCUIT COU 7 Notary Pubtic
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By ____.:~~~~~1L ~ ~ .C. My Commission expi~es
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- (To be oxecuted in duplicate and original filed with Clerk Gircuit Couri, and duplicate with 7ax Assessor.)
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