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Declaration nt Domicile and Citizensl~ip
TO THE STATE AND COUNTY TAX ASSESSOR, jQ~~S
V•7
51. LUCIE COUNTY, FIORIDA:
This is my declaralion of Domic~le and Citizenship in the State of Florida 1i~at 1 am filing this day in accordance and
:n con(ormity with Chapter 222, Section 222.17, Florida Statutes. `
L~~ ~ ~o~n, ;
1 was formerly a lega) resident of ~rOd^ 1~1a.~-.- _ ~ -
3 ~ ~ ~ 1 ~ ~City) (State) ;
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and 1 resided at ' 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
~ _ , 19 and I reside ~at ~
Q~ ~ ~ N ~ a.~ •
' (Street and Number)
FOR? 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 pertine~t 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 : `
~ FILfO RND RECORQ~D ~
- ~Y~~ C~ C~ e( ~y n~ S~~~,,,111 ~T. LUCIE COUNTY F~A. +
1 , ROCER POITRAS
~ CLERK CI~~UIT COURT ~ '
RFCONC VERiFtED.~~
O~) i M ~ t h~ S~%._.
I OCT 9 II 34 AM'~Z
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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 I have no intention to return to my former domi~ile, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. ~
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~ ' (Name)
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~'~,~;.'j ~°~it~cAbed before me this day of Q''~~~~ . 19-2~• '
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' dqi~r~~g . Po~tk~s. ' i
I~"~~CI~~ COURT Notary Public ~
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By D.C. l~hy Commission ,~xpires
(To be oxeculed in duplicate and original filed with Clerk Circuit -Courf, snd duplicate with Tax Assaswr.) ~
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