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Declaratjon ot Domicile and Citiaenship ~
;
TO TNE STATE AND COUNTY TAX ASSESSOR, ~
2~052
Sl. IUCIE COUNTY, FLORIDA:
This is my declaration of ~omicile and Cit~zenship in the State of Florida that I am filing this day in accordance and
in conformity with Chapter 222, Section 222.17, Florida Statutes.
I was formerly a legal resident of -_f["~-L"~ - -
(City) (State)
and I ~esided at ~~~Q~~~y`-'J~LC- However 1 have changed my domiCile
~~~=G~ (Street and Number) ~y~t~•t
, ~ ~
to and arn and have been a bona fide resident of the State of Flonda since _-,~_Q__--------- day of
~ B ~ /l , ~ ~
~~~~f~L~__, 19~~, and I ~eside at 'u
(Street and umber)
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 a~y pertinent facts, such as sale of property or business, or relinquishment of employment
at former domicile, re~noval of family to new domicile, purchase of home, etc.)
Applying f for Homestead
Entering children in school ;
~~iTr~ i~~-'~'-' ~~rrs~wr~.~~ ~GE ~
FIIED AND RECOROEp '
i~. WCIE COUNTY flA.
ROCER POITAAS
CLERK CIRCUIT COURT y~
RECORD YERIFtEO~iC
; ' SEr 1~1 2 02 PH'11
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~ 238052
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I FURTHER CERTIFY that I will comply with all other requirements of a legal resident of this State.
I FURTHER CERTIFY that I have ~o intention to return to my former domi~ile, and 1 intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORI~A, permanently.
• ~ . ~1~-L~'~/'~ `~'~.~.c.P
(Name)
V : . C' J'',~ _
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~s . i~~ ~~.s . ~~i` ~C./
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' ~ t O (Address)
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~•••..~Sw~a~n~to'and subscribed before e this day of _ . 19
_ P .
•
ROGER POITRAS -
CLERK CIRCUIT COURT Notary Pubtic
By \ i~ D.C. My Commission expires
(To be execufed in duplicate snd original filed with Clerk Circuit Court, and dupliwte with ?ax Assessor.)
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