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10 TNE STAIC /1ND CUUNIY iAX ntiSIS,SOR, •
Sl. IUCIE COUNTY, F~oR~uA: 253145 ~
This is my declaration of Oomicile and Citizenship in thQ Slate of Florida that 1 am filing ihis day in accordance and
in con(o~mily with Chapter 222, Section 222.17,- Florida Statutes. . ~
1 was fo~me~ly a legal resident of ~
. (City) ~ (State)
3 ' ~(.~~V"~ ~ . However 1 have cha ed my domiCile
and 1 resided at ~ / _ ~
• ' (St~eet and Number)
to and am and have been a bona fide resident of the State of Florida since ~ day of ~
~ t ~ a ~ / ~ cs. ~~U ~ c~~-taC~/~ ~ ;
, 19 A), and I reside at
- (Street and Number)
~
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA ~ ~ ~
a~c1 this stafement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Florida. ~
qnsert here any pertinent facts~ such as sale of property o~ business, or relinquishment of employment ~
af forme~ domicile, ~emoval of family to new domicile, purchase of home, etc.) ~ -
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- Entering children in school :~f
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• S? ~YGE COiti~T? RL
; . . ' - Ri~t~~ ~Bi~S
~ ~ ~ • CLERK CI~tC1i1T ~OURT
' RFCORO YER'•~IED
; ~ _ . - ~ - ~ ~ 30 9 i~ l~1'73
f
~ • ~ - 253145 - -
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1 FURTHER CERTIFY that I wil) comply with all other requirements of a legal resident of this State. ~
1 FURTNER CERTIFY that I have no intention to return to m former domitile, an intend to remain in FORT
PIERCE, SAINT LUCIE COUN?Y, FIORIDA, permanently. ~ ~ ~
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~ Sworn to and subscribed before me this day of , 19 j
~ . ~ • ~
ROGER POITRAS , _
GLERK CIRCUIT COURT Notary Public
.
E~y G i~.C. My Commissian expires - ~
, sooK 21~ ra~t ~.~G~
(To be oxocutod an durlicsto and .•~~S ~1 (iI~J with Uerk Circuit CouN, and duplicato with tax Assossor.;
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