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lv THL STAIE /1NU CUUNIY TAX /1ti5LS.~OR,
51. lUC1E COUNIY, FLpRIDA: - 25~~ ~
This is my declarotio~ of Domicilc and Citizcnship in tho State of Florida that 1 am fili~g this day in accordance ancl
in conformity with Chapter 222, Settion 222.17, Flotida Statutes. - . •
1 was formerly a Icgal ~esident of . ~m ~
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and 1 ~esided at ~x 9y~/-A 2t[nT~'~- ~ ' However I have changed my domitile
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i~ and am and have been a bona fide ~esident of the State of Florida since ~~h ~`J`'~Q'~` day of
~~~c.c1~ ~h , 19~.3., and 1 ~eside ~at '~Q~O so 35th--~tN o o~~" ~
• (Street and Number)
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fORT PIERCE, SAINT LUCIE COUNTY, FLORIDA ~ ~
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Florida.
pnse~t here any pe~tinent facts, such as sale of property or business, or relinquishment of employment ~
at fomne~ domicile, removal of family to new domicile, purchase of home, etc.)
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- Entering children in school : ~
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1 FURTHER CERTIFY fhat I will comply with all other requirements of a legal ~esident of this State. ~
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1 fURTHER CERTIFY that I have no intention to return to m former domicjle, and I intend to remain in FORT ~
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PIERCE, SAINT LUCIE COUNTY, FIORiDA, permanently. ' K~ ~r.~ ~,c~5~ ;
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,~~~t~tY~~nr~•s~bsuibed before me this ~ day of . 19 ;
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ROGER POITRAS ~
CLERK CIRCUIT COURT Notary Public
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8y ~ D.C. My Commission expires
~ eooK 213 PACE 4~6 ~
(To bo oxoculeJ an duplicato anJ ~~•~inal filcd wilh Clerk Ci~cuit CouN, and duplicalo with 7ax Assossor.)
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