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. DE~.cfarafi~n af Do~nicite :ic~d Citirensl~~p
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TO THE STATE AND COUNTY T/1X ASSCS.SOR. 250446 r
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Si. LUCIE ~OUNTY, FiORtDA: ~
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This is my declaralion of Domicile and Citizenship i~ the State of Florida that ! am fiting this day in accordance and
in confo~mity with Chapter 222, Section 2.17 larida Sta es. • .
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I was formerly a legai resident ~ " ~
(~ity) (State)
and I resided at ~ . However I have chan ed m domiti~e
9 Y
• (Street and Number) ~ ~
to and am and have been a bona fide resident of the State of florid since !7!1~_~~ day of
- ~ _ , 19~, and 1 reside ~at ' ~ ' ~
. ~ (Street and Numbe~)
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
and this stateme~t 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 forme? domicile, removal of family to new domicile, purchase of home, etc.) ~ ~
Applying~ for Homestead ' .
- nteririg children in school :
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1 FURTHER CERTIFY that I will comply with all other requirements of a tegat resident of ihis State.
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li I FURTHER CERTIFY that I have no intention to return to my former domic,ile, and 1 intend to remain in FORT
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; PIERCE, SAINT Ll1CIE COUNTY, FLORIDA, permanently. ~ .
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' ~~'~~n.. ~~I~w'1o and subscribed before me this day of ~A , 197~:..~f- ~
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` ROGER POITRAS
~ CLERK CIRCUIT COURT Notary Public
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~ ay O.C. My Commission expires ;
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g~oK 212 ~A~E 776 , . ~
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(To be oxocuted in duplica~o and origi~al filed wilh Clcrk Cireuit Court, and duplicalo with Tax Assessor.) !
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