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Deciaration ot Domicile and Citizenship
TO THE STATE AN~ COUNTY TAX ASSESSOR. 242309
51. LUCIE COUNTY, FLORIDA:
This is my detlaration of Domicile and Citi2enship in the State of Florida that I am filing this day in accordance and
~n conformity with Chapter 222, Section 222.17, Ftorida Statutes.
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I was formerly a legal resident of ~~~~'>?~'L_
(City) _ - - - - ~State) _ ,
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s,.~ 7 , .,-~-~~ZGGf_- However I have changed my domiCi~e i
and 1 resided at _ /~~/L
(Street and Number)
to and am and have been a bona fide resident of the State of Florida since . :~S day ot
, 19__ , and I reside at ~7_. ,1,1~F -
(Street and Number)
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 properry or business, or relinquishment of employment
- at former domicile, removal of family to new domicile, purchase of home, etc.)
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F~tEO RNO RECORDEp
St• LUCtE COUMtr F~~. i
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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 domicjle, and I intend to remain in FORT ;
~
~ PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. , ~
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~ ~ ",CL~(J:;.;- - - (Name) ~
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-~vv~ to and subscribed before me this day of -~?~'~??z~~~'`' , 19~
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~ ROGER POITRAS _
~ CLERK CIRCUIT COURT Notary Public ~
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~ By ! -i!~~~~~~~ C D.C_ My Commission expires ~
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(To be execu~ed in duplicate snd original filed witl~ Clerk Grcuit Court, aRd duoliuh with Tsx Assessor.) ~
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