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lU TI1E 51~~11C AND CUUNIY TAY /~:~~E.S.tiOk. 252~3 ~
51. LUCIE COUNTY, FIORIDA: ~
This is my dctlaralion of Domicilc a~d Citizcnship in tho State.of Florida that 1 am liling ihis day in attordanta anJ
in con(ormity with Chapter 222, Setlion 222.17, Florida Statutes. . ~
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1 was fomne~ly a legal resident of b ~
~Ciy~ (State)
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,~~~Q~~D i~//CLl./L o?~I_~ ~ . Howeve~ 1 have changed my domitile
and I resided at -
• ' (Street and Number) •
to and am and have been a bona fide resident of the State of Fiorida since day of
' , 19.~.-, and I reside ~at ' l ~ 0 ~ ~ ~
- (Street and Number)
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FORT PIERCE, SAlNT LUCIE COUNTY, FLOftIDA '
and ihis 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 prope~ty or business, ot relinquishment of employment
af fomner domicile, ~emoval of family to new domicile, purchase of home, etc.)
Applyinq, for Homestead _ ~ -
- Entering children in school : ~ ~ ~
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I FURTHER CERTtFY that I will comply with all other ~equirements of a legal resident of this State.
1 FURTHER CERTIFY that 1 have no intention to return to my former domiule, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIOA, permanently. ' h a" d- a a~t F n/
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T. • c~~' : • . (Name) _
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~'e - ;~~t~e = (Address)
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Swortt~~p?W1tI' subscribed before me this day of , 1 q~3
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ROGER POITRAS ~
CLERK CIRCUIT GOURT Nofary Public
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[ly C D.C. My Commission expires
becx F~cf 55i .
(To be oxocuieJ an duplicato and ~~•:na! filed wilh Clork Citcuit Court, a~:d duplicato with Tax Assoswr.)
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