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. D~cl~ir~;(ion ot t~ornicile ar,ti CiYi~ en~t~ip
• 25143`7
TO TI1E STATE AN~ C~UN1Y TAX ASSCSSOR,
Sl. IUCIE COUNTY, FLORIDA: '
This is my decl~ration of Domicile and Cit~zenship in tho S1a~e of Florida that 1 am fili~g this day in acco~dance and
in conformity with Chapter 222, Scdion 222.17, Florida Statutes. .
1 was fomnerly a legal resident of
(City) (State)
and I resided at ~ . However 1 have changed my domiCile
- (Street and Number) • .
. ~ .
to and am and have been a bona fide resident of the State of Florida since day of
. ~ ~ ~~eG ~-t~thi, ~~~~-G~c,t~-
_ ' _ , 19~_~!and 1 reside ~at
~ (Street and Number)
. ~
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
and this statement is to be taken as my decla~ation of citizenship, actual legal residence a~d domicile in the State of Florida.
qnse~t here any pertinent facts, such as sale of property or business, or relinquishment of employme~t
at former domicile, removal of family to new domicile, purchase of home, etc.) ~ ~
- ~ 25143'7
Applying, for Homestead ~ -
. ~ ~~~~°~~~l. ~
- Entering children in school : ~,g~t~c ~;~~y~ ~q~
_ ~ECORO rE~rF~EO~.,~~
- ~'R ~ ~ Si ~'13
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I FURTHER CERTIFY that 1 will comply with all other requirements of a legal resident of ihis State.
I FURTHER CERTIFY that I have no intention to return to my former domitile, and I intend to remain in FORT
PI~RCE, SAINT LUCIE COUNTY, FLORIDA, permanently. ~
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:'~~J~.~~.....~E" . (Name)/+'
= ~Q' ~~1~~ r ~ ~ ~G~'• f~EDt,e/C k ~`1~7~C ~1.e L L
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J, • ` :o.'' - ' - (Address) _ }
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• 1 ~ • GO\~~ • ~=1 ~
,'~~''~~p~~fiptbnd su~iicribed befo~e me this ~ day of , 19~. ~
.
,..R_ _ ,
_ , _
ROGER POITRAS
RK CIRCUIT COURT ' Notary Public
. ~
t3y D.C. My Commission expires
,
(To bs oxocuted in duplicalo and o~iginal filq4! R i1h Clork Circuit Courf, and duplicata wilh Tax A:sossor.)
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