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. Declaration of Domicile and Citizenship
TU THE STATE AND COUNTY TAX ASSESSOl2, `,~~A~~
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Si. IUCIE CUUNTY, FIORIDA:
This is my declaration of pomicile and Citizenship in the State oF Florida that I am filing this day in accorda~ce and
~n conformity with Ct~ap9er 222, Section 222.17, Florida Statutes.
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1 was formerly a legal resident of _ _ ~11~y~----- _'-L~!'' ~ -
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~ Kity) (State)
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a nd I resided at U~ _c ~_~.c~e c~
A c'~ . 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 .!_In day of
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~r~~S~-c1S_.~------------. 19..~~-, and 1 reside ~at _~1~_-I,VPSr 1.~cc~ ~ c~~v• ~~LCy_4s_. ~
(Sireet and Number) ~
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FORT PlERCE, SAINT LUCIE COUNTY, fLORIOA
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and this statement is to be taken as my declaration of citizenship, actua! lega) residence and domicile in the State of Florida.
(Insert 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.)
Applying ? for Homestead - s
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Entering children in school ~""``c ~-''`',j`'~"' ~
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RECORD YERIFIED
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1 FURTHER CERTIFY that I will comply with all other requirements of a legal resident of this State. #
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I FURTHER CERTIFY that 1 have no intention to return to my former domiGle, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. ~ ~ ;
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~ ' " ' (Name) ~%AvNF i2
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.5y~!or».tA•~d,~4bs~ribed before me this day of ~ , 19L~
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ROGER POITRAS
CLE~ CIRCUIT COURT Notary Public
~ E3y ~ D.C. My Commission expires
(To be executed in duplicate and original filed with Clerk Circuit Court, and duplicate with Tax Asseswr.)
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