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Declarat~on ot Domicile and Citizenship
TO TNE STATE AND COUNTY TAX ASSESSOR. ~`*~S /
51. lUC1E COUNTY, FLORIDA:
This is my declaration of Domicile and Cit~zenship in the State of Florida that I am fil;ng this day in accordance and
~n conformity with Chapter 2~2, Section 222.17, Florida Statutes.
1 was formerly a legal resident of -
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~C,ty~ ~ (State)
1 ~ Howeve~ I have changed my domiCile ~
and 1 resided at _ ~ \~1.~''-'~C.~J - -
(Street and Number)
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to and am and have been a bona fide resident of the State of Florida since ~ _ day of
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. 19-~'5--, and 1 reside at ~C lL ~ ~-~~_-~t.~L~-
(Street and Number)
FORT PIERCE, SAINT lUC1E COUNTY, fLORIDA
and this statement is to be taken as my declaration of citizenship, actua! legal residence and domicile in the State of Florida. ;
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(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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~ I FURTHER CERTIFY that I will rnmply 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 domiGle, and I intend to remain in FORT ~
PIERCE, SA1NT LUCIE`~OUNTY, FLORIDA, permanently_ ~
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•5~ - • j~~ j ~ i (Name)
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Sworn to and subscribed before me this ---t~ day of - . 19~
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~ ROGER POITRAS
Notar Public
~ CLERK CIRCUIT COU T Y
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(To be executed in duplicste and original filed with Clerk Circuit Court, and duplicate with Tsx Assessor.)
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