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Declaration ot Domicile and Citizenship
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TO THE STATE ANU COUNTY TAX ASSESSOR, ' ;
238888 ~ ~
Si. IUCIE COUNTY, FLORIDA-
This is my declar~tion ol Domicile and Citizensh~p in the State of Florida that 1 am filing this day in accordance and
~n conformity with Chapter 222, Section 222.17, Florida Statutes.
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I was formerly a legal resident of -_~`~~Q/_------ -
~C;ty~ (State)
and I resided at _ _ Q~ _ , - _ _ _ _ _ However 1 have changed my domiCile ;
(Street a~d Number)
to and am and have been a bona fide resideM of the State of Florida since day of
19 and I reside at _ ~~~0 J .
~ (Street and Num er)
FORT PIERCE, SAINT LUCIE COUNTY, fLORIDA
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 relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
Applying ~ for Homestead
Entering children in school : - n G~G~y
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RECORO VER~Ft
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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 1 have no intention to return to my former domi~ile, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, pe~manently.
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;``4 ~S Vµ ~COG', (Name)
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~`'•`~C ~$worl~?o'and subscribed before me this day of ~~L~~ , 19 7Z
.
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ROGER POITRAS -
CLERK CIRCUIT COURT Natary Public
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dy ~u~~ ~~'<<~ D.C. My Commission expires _
~ (To be executed in duplicate and original filed with Clerk Circvit Couvt, and duplicate with ?sx Assessor.)
~ooK 20 fi ~act 2339
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