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DeClaration of Domiciie and Citizensi~ip
TO TNE STATE AND COUNTY TAX ASSESS~R. 239906
Sl. LUCIE COUNTY, FLORIDA:
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This is my ded~ration of Domicile and Citizenship in the State of Florida tliat I am filing this day in accordance and
in conformity with Chapter 222, Scction 222.17, Florida Statutes. !
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1 was formerly a legal resident of ~
~C;ty~~ (State)
and 1 ~esided at _~11_! ~,~,~G~jQ " • - . However 1 have changed my domicrile
(St~eet and Number)
to and am and have been a bona fide resident of the State of Florida since / ~ day of
~
~ , 19--, and I ~eside ~at ~ ,
' (Street a Numbe )
~nRT PIER~E, SAlNT lUClE CQUNTY; FLQRIDA ~ _
and this stateme~t is to be taken as my declaration of citizenship, actual lega) residence and domitile in the State of Florida.
(Inserf 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 :
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1 FURTHER CERTIFY that 1 will comply with al) other requirements of a legal resident of this State.
1 FURTHER CERTIFY that I have no intention to return to my former domiple, and 1 intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. '
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~'vPa~e~t~~~•iubscribed before me this day of - ~C ~ , 19L_1~'
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ROGER POITRAS
CLERK CIRCUIT COURT ~ Notary Public ~
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By r .C. My Commission expires
(To be oxocuted in duplicate and oric~inal filed with Clerk Circuit Court, and duplicate with Tax Assossor.) ~
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