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1C) Tlil•.S1A1L AND CUUNIY Tn:C /~:~~~E.S:.C~k, ~
51. IUCIE CDUNTY, FIO~IDA:
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This is my decla~ation of Domicile and Cilizenship in thQ Stato of Flo~ida ~hat 1 am filing this day in accorda~ce and ~
in conformity with Cl~aj~ter 222, Sectio~ 222.17, Flo~ida Statutes. . ~
I was forme~ly a Icgal resident of ~~n~~~. (
O~N N
~ (City) . (State)
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end 1 resided at ~ _ . However 1 have changed my domiCile
• ' (Street and Number) •
to and am and have been a bona fide resident of the State of Florida sinte day of
_ ~ • , 19 , and I reside 'at ' ~ ~ - ~
~
• (Street and Number)
:
FORT PIERCE, SAINT LUCIE COUNTY, FLORIbA ~
and this 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 property or business, or relinquishme~t of employment
at former domicile, removal of family to new domicile, purchase of home, etc.) ~
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Applyinq, for Homestead . _ ~ ~ ;
~
J Entering children in school : . ~
~ - . ,~~yl d~a ~G~b~~i,~s ~ ~ -
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, - F! LEO ~hQ ftECORp.~ ?
. ~ l.Q~-~ ' . S~T.LUCIE COUNTY:P.LA. ~ -
ROCE~ ?OITR~S
~ CLERK CI~CBIT.COURt ~J~
' ~ RECORD VER~FIED~..~..1'._
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. . . ~ - ~ ~ !~r 3 - ~A ~3 AN'73 -
i ~ . ~ - . 25344'7
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1 FURTHER CERTIFY that I will comply with all other requirements of a legal resident of this State.
1 FURTHER CERTIFY that t have no intention to return to my formet domiGle, and I intend to ~emain in FORT
PIERCE, SAINT LUCIE COUNTY, FIORIDA, permanently. '
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~ Swo~~ ~o and subscribed before me this day of , 19 .
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ROGER POITRAS
CLERK CIRCUIT COURT Notary Public
43
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Dy D.C. My Commission cxpires s
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(To be oxocutod jn duplicato and ~•~~nal filed witl~ Clork Circuit ~Court, a~.d duplica~o with Tax Assosso~.)
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