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1 U TI IC STA1 E/~ND CUUN1 Y T/~X ~SOF:, 253019 ~
51. lUC1E COUN1 Y, FIORIDA:
This is my declaralion of Domicile a~d Citizcnship in thcs State of Florida that I am filing this day in acto~dance and
in con(o~mity with Chapter 222. Section 22?.17, Flo~ida Statules. . ~
1 was formerly a legal resident of ~
. (Ciy) (State)
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and 1 resided at /L~~~ • . Howeve~ 1 have changed my domitile '
• ' (St~eet and Number) . • ~
to and am and have been a bona fide resident of the State of Florida since day of
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~ , 19~~' and 1 ~eside ~at ,
~ (Str and Num r)
FORI' PIERCE, SAiNT LUCIE COUNTY, FLORIDA ~
and this statement is to be taken as my declaration of citizenship, actual legal residence and domitile in the State of Florida.
(Inse~t here any pertinent facts~ such as sale of property or business, or relinquishment of employment '
at fo~mer domicile, removal of family to new domicile, purchase of home, etc.) ~
Applying~ for Homestead . ~ ~
- Entering children in school : ~~~D ~
' ~-~IE `CBYIIi'I ~iLM.
' ~CER POtTR~13 • ~ '
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, . RECORD YEItIFyED
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1 FURTHER CERTIFY that I wil) comply with al) other requirements of a legal resident of this State.
I FURTHER CERTIFY that 1 have no intention to ~eturn to my former domicjle, and 1 intend to remain in FORT
PlERCE, SAINT LUCIE COUNTY, FLORIDA, permenently. '
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Sworn to and subscribed before me this G day of . , 19~ ~
.
ROGER POITRAS
CLERK CIRCUIT COURT Notary Public
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3y D.C. My Commission cxpires
(To bo oxoculed ;in duplicato and ~ •~nal fileJ with Clark Circuit Court, a~:d duplicato with Tax Assoswr.~
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