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lU THC Sl/11t- /1ND COUNTY T/1X /1ti~i.S~OF:, ~~~O~r .
51. lUCIE COUNIY, fIO~IDA: ~ ~
Thit is my dcciaration of Domicile and ~it+=enship in 1ho Sta~e of Flo~ida that i am filing this day in accordance ancl
in conformity with Chapter 222, Section 222.17, Florida Statutes. . ' _
1 was formerly a legat resident of •
- (City) - (State)
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and ! resided at ~ '
. However 1 have changed my domicile
' ' (St eet and Number) •
to and am and have been a bona fide resident of the State of Florida since day of
~ , 19~, and 1 reside 'at • ~ a~~n~~/v~~~~-~
' (Street and Number)
~
~ORT PIERCE, SAINT LUCIE COUNTY, FLORf~A - -
end this statement is to be taker~ as my. declaration of citi2enship, actual legal residence and domicile in ihe State of Florida.
qnsert he~e any pertinent facts. such as sale of property or business, or relinquishment of employment
at fornner domicile, removal of family to new domicile, purchase of home, etc.) _ ~
Applying, for Homestead . ~ ~ .
- Entering children in school : ~ . ~ -
. ~ ~ ~ ~ ~ ~il//1/ - ~ v f~i3- ~ i
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. ? ~l ~I ~ < ~ - fJ !/U RE .6l~~YEP!F~E~~ U .
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1 FURTHER CERTIFY that I will comply with all other requirements of a legal resident of this State.
~ . ,
t FURTHER CERTIFY fhat 1 have no intenfion to :etum to my former domic,ile, and ! intend to remain in FORT
j PIERCE, SAINT LUCIE COUNTY, FIORIDA, permanentlX. '
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' i.; J! 7':..-C'~% s fi, ; • (Name) L G~ l~a f~~?
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ibed before me this day of ,~q~
' ~ 7E4irtint~~~t .
f , . , .
ROGER POITRAS "
CLEItK CIRCUIT COURT Notary Publit
~ •
~ QY ~ D.C. O R M Commission expires
~ - sooK2~3 PA~2~2i
(To bo oxocutod an duplicato and -••~naf fi1~J wilh Clork Cirtuit Coutt, and duplicato with Tax Assoswr.)
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