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~ 252149
lU TNE ST~11C ANU CUUNTY lAX l~SSLS.SOk, ~
Sl. IUCIE COUNIY, FIORIDA:
This is my declaration of Domicilc and Citizenship in thc Sta~o of Ftorida that 1 am filing this day in accordance and ~
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in confo~miiy with Chapte~ 222, Section 222.17, Fla~ida Statutes. . ~
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I was forme~ly a Icgal ~esident of • ~ }
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end 1 resided at _ ' . Howeve~ 1 have changed my domic,ile :
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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~, and I reside 'at • Q ~
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FORT PIERCE, SAINT LUCIE COUNTY, FLORI~A ~
and this statement is to be taken as my declaration of citi2enship, actual legal residence and domicile in the State of Florida. `
I'n uishment of em lo ment ~
(Insert he~e any pertinent fads~ such as sale of property or business, or re i q p_ Y ~
at former domicile, removal of family to new domicile, pur.chase of home, etc.) .
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Applying~ for Homestead . - ;
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- . Entering children in school : ~ ~ ~
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~ ~EO ~a RECORp~p' ~ ~
i~.lUC1E COUMIY fLA. ~ ~
' IlOREA P.OITRA: ~ ~
- CIERK C1~G1}IT COUI~1' ~
- RECOROIrERlFIEO~.~...~.,.
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1 FURTHER CERTIFY that I will comply with all other requirements of a legal resident of this State. ~
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t FURTHER CERTIFY that I have no intention to return to my former domiCile, and I intend to remain in FORT 1
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PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. ' ~
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••~v'~' • ~~S ~ e (Name) W oS/rI~~TH
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~'~rSvirorn'io~antl subscribed bsfore me this day of ;
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R~GER POITRAS , ~ ` ~
CL K CIRCUIY COURT Nolary Public ~
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[~y ~.C. My Commission cxpires ~
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(To be oxoculed -in cluplicalo and ~~~~~~al filecl witl~ Cle~k Circuit Court, and duplicato with Tax Assoswr.) j
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