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Declaration ot Domicile and Citizenship ~
TO TNE STATE AND COUNTY TAX ASSESSOR, ~~~3
`.l. LUCIE COUNI'Y, FLORIDA:
This is ~ny declaration of Domicile and Citizenship in the State of Florida that 1 am filing this day in accordance and
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~n con(ormity with Chapter 222, Section 222.17, Florida Statutes.
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I was formerly a legal resident of . - - --~~~Y_Li - _ .it_
(C~ry) (St
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and I resided at ~____~-__~d~_~2-,~-s~-- However 1 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
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. 19~~ and I reside at 1~~~~
tr e ~ Number)
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FORT PIERGE, SAINT LUCIE COUNTY, FLORIDA ~'GG"`~"
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in ihe State of Florida.
(Insert here any pertinent facts, such as sale of properry or business, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
Applying j for Homestead -
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'tering children in school : y~ ~Q2~~
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~~~NO Recoa~~ ~
' L IE ..OUMTY p~
lIOCEIt P0ITRAS t, ~
~ • RECORD YERI~FjEp COU~.~.~.~1~.
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~ SE,r 19 1011 IN~'71
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238233
1 FURTHER CERTIFY that I will comply with all other requi~ements of a legal resident of this State.
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I FURTHER CERTIfY that I have ~o intention to return to my former domiGle, and I intend fo remain in FORT !
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. ~~+D }
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~,.,:,~~.rlj;;«f~.,~;f~ - (Name) ~
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t., '•5wo+~rY't~.anc1 subscribed before me this day of S~~ , 19 ~ 1i
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ROGER POtTRAS
CLERK CIRCUIT COUR Notary Public
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E3y _ D.C. My Commission expires
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(To be executed in duplicate and original filed wifh Clerk Circuit Court, and dupliwte with Tax Assessor.)
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