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10 THC SiAIE AND COUNIY ThX ASSES:~OR, ~~~~yno
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.i . LUCtE COUNI Y, FLORIDA: • ;
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This is my declaralion of Uomicile and Citicenship in the State of Florida ~hat ! am filing this day in accordance and
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,n canformity with Chap~er 222, Sedion 22~.17, Florida Statutes. . ;
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I was formerly a legal resident of ~CIIt-i v~-
(City) (State)
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anci 1 ~esided at However I have tha~ged my domiCile
(Street and Number)
to and am and have been a bo~a fide resident of the State of Florida since _ ~ da of .
T y ,
, 19~~., and I reside ~at ~
treet and Number)
FORT PIERCE, SAINT LUCIE COUNtY, fLORtDA
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 property or business, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
App~yingj for Homestead ~ .
- Entering children in school : .
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ST- LU~~~ ::iUh;1! F1~1.
E~ pCC~ a r i~ir~~$
RF Cl EF[ 1+T COURT
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. ' . A~a ID I 44 PH'l3
251,
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1 FURTHER CERTIFY that 1 will comply with aIl ofher requirements of a tegai ~esident of lhis State.
I FURTHER CERTIFY that 1 have no intention to return to my former domiCile, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, perma~ently.
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•••.CO~:
• ~ (Name)
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.S~~3onC~~a~d subscr;bed before me this _ lU day of ,~q~L~
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ROGER POITRAS _
CLEItK CIRCUIT COURT Notary Public
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C-_ U.C. AAy Commi;sion expires
ao~K 212 ~~~f 25~.6
(To be oxocutcd in duplicalo~anJ oriqinal (il~d will~ Clcrk Circuit Court, ond Ju~~licalo witl~ Tax Assossor.) i
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