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• ~~LC`c~fi'i1C}fl UP ~Uti1i: i~:: i!lt~i Gi~i::C,'11;i~e~~!
lU THE STAI[; /1ND CUUNIY TAX AS:f.~tiC~h,
Sl. LUCIE COUNI'Y, fIORIDA: 2~23
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This is my dcclarolion of Domicilo and Cititenship in tho State of Florida that I am (iling this day in accordance a~d
in con(o~mity with Chapte~ 222, Sectio~ ?2?.17~ Flo~ida Strtutes. , ' ,
1 was formerly a legal resident of ~ Q../E_~ p w/~ -.C L~~`.U v i S
(City) (State)
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and 1 ~esided at 1- te. C/~ i~Q. ~ . However 1 have changed my domiu~e
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to and am and ~?ave been a bona fide resident of the State of fiorida since S" 7~ day of ~
• l o- S , 19~, and 1 reside ~at 3 2. .3 Gl ~Z A I.~ /Z /~/~/d• r~t c~. '
- ' . (Street and Number)
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FORT PlERCE, SAINT LUClE COUNTY, FLORIOA - ~ ~
and this statement is to be taken as my declaration of citizenship, actual legal ~esidence and domicile in the State of florida,
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(I~sert here any pertinent factsF such as sale of property or busi~ess, or relinquishment of emptoyr~ent
af former domicile, removal of family to hew domicile, purchase of home, etc.) _ '
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Applying, for Homestead _ - ~ ~ .
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- Entering children in school ; _ ~ -
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si• wc+~ couMTr F~~.
A . - ROCfA~r~017RAS ~ ~
U ~ RE O~RO yFaRG~~j ~pURt
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1 FURTHER CERTIFY lhat I will comply with al) other ~equi~ements of a legat ~esident of fhis Stafe.
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4 1 fURTH~R CERTIFY that I have no intention to return to my fo~mer domiGle, and 1 intend to remain in FORT
j P(ERCE, SAINT LUCIE COUNTY, FLORIDA, permanently, '
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L~?IT., C~'•.,,- . • (Name)
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yr,. ~p ,7~~ subscribed beFore e this day of - ~ , ~q~~
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ROGER POlTRAS '
~ CCERK CIRCUIT COURT Notary Public
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i ay O.C. My Commission expires
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~ (Yo bo oxocufod ~n duplicslo and .••~nal filoJ wilh Clork Circuit Court, a~.d duplicato wilh Tax Assossor.)
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