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Decla~atlon ot Domicile and Citizenship
TO THE STATE AND COUNTY TAX ASSESSOR, j~4~~i
51. LUCIE COUNTY, FIORIDA:
ihis is my declaration of Oomicile and Citizenship in the State of Florida that I am filing this day in accordance and
~n conformity with Chapter 222, Section 222.17, Flo~ida Statutes.
I was formerly a legal resident of ~lt a- -
- ~~^G~ (Ciry) (StateJ
and 1 resided at Z?'1 - ~~~~'~~'~C~""-'~- However 1 have changed my domic,ile
(Street and Number)
ro and am and have been a bona fide resident of the S1ate of florida since ~ day of
_ _ , 19_,~, and I reside at ~V_~ ~~'`-----L--=r s/~". - -
(Sireet and Number)
FORT PIERCE, SAINT LUCIE COUNTY, fLORIDA
and this statement is to be taken as my declaration of usizenship, actual legal residence and domicile in the State of Florida.
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(Insert he~e any pertinent facts, such as safe of property o~ business, or relinquishment of employmznt ~
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at fo~mer domicile, removal of family to new domicile, purchase of home, etc_)
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FaEO.NO RECOROEO ~
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RECOR~ t ~r:c,E~ r~ n ;
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~ I 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 I have no intention to return to my former domi~ile, and I intend to remain in FORT g
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PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. ~ i
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~ • , (Name)
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•-Sv~o~nrt8 and subscribed before me this day of - G' _ ~ , 19~?! ;
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~ ROGER POITRAS t
~ CLERK CIRCUIT COURT Notary Public s
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- gy _ ` ! ~~f/" ~>lt~~- D.C. My Commission expires
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(To be executed in duplicate and original fited with Clerk Circuit Court, and duplicate with Tax Assessor.)
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