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Deciaration ot Domicii~ and Citizenship
TO THE STATE AND COUNTY TAX ASSESSOR,
Sl. I.UCIE COUNTY, FLORI~A: 23~3~3 .
This is my declaration of Oomicile and Citizensh~p in the State of Florida that I am tiling this day in accordance and
~n conformity with Chapter 222, Section 222.17, Florida Statutes.
1 was formerly a legal resident of . __~~!.!'_U _ _ ,O _
(Ciry) (State) ~
and 1 resided at _~~l
!_C_~ - -1~?~-'-- - - - - However I have changed my domiCile
~ (Street and Number)
to and am and have been a bona fide resident of the State of Florida since ` day of
---SE' ~t'M~ ~t Y •19~~!, and I reside ~at U YJ~~
~ (Street and Number) _
~
FORT PIERCE, SAINT LUCIE COUNTY, FIORIDA
and this,statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Florida.
(Insert here any pertinent facts, such as sale of property or business, or relinquishme~t of employment i
at former domicile, removal of family to new domicile, purchase of home,.etc.)
Applying, for Homestead
Entering children in school ; ~tL~DAh~ ki~~
~ 1'tfClf CpWitT~'
l / ~LEP.K C;:::,t;IT~Cq~tT ~j(
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I FURTHER CERTIFY that I will comply with all other requirements of a legal resident of this State.
1 FURTHER CERTIFY that 1 have no intention to return to my former domi~ile, and 1 intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
. Qs2 ~z.~
~ ; , Name)
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~ ~
~ . . ~ ~ La r '
~ O/ ~ ~j ~ ~
~ . (Address)
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Sworn to and subscribed before me this - day of L~ , 19 7y
~ . . :
~ - ; .
~ . ROGER POITRAS _
~ CLERK CIRCUIT COURT Notary Public
.
~ _
Ly D.C. ~ My Commission expires
(To be executed in duplicate and original filed with Clerk Circuit Court, and duplicate with Tax Assessor.)
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