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:l. lUC1E COUNTY, FLOF:IU/1:
This is my dcclaration of Domicile and Citizcnship in the State of Florida ~liat 1 am tiling this day in accorclance and
in con~ormily with Chapte~ 222, Section ?22.17~ Florida Statutes. , ' .
1 wa: formerl a le al resident of ~ G~i
Y 9 ;
• (City) • (State)
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and I resided at . However t havc changed my domitile
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to and d have been a. bona fide ~esident of the State of Florida since ~ day of '
~ , 19.L;, and t reside ~at ' ~ a ~ ~ ~ '
v ~ ~nd Number) ,
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FORT PIERCE, SAINT LUCIE GOUNTY, FIORIDA • •
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and this stateme~t is to be taken as my decla~ation of citizenship, actual lega) residence and domicile in the State of Fiorida.
~(Ins~rt here any pertinent facts,. such as sale of prope~ty or business, or relinquishment of employmer~t
at former domicile, removal of family to new domicile, purchase of home, etc.) , . ~
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" ~Applying; for Homestead ~C'~!~t~C~i ~~a~~~~+~ _ ~ - •
- Entering children in school : ~ . ~ - . ~ • ~
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. . - - . : 259403. . ~ ~
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~ - • ' ' - . ftLFO AM~ 4E~DR~D -
. ' ' ~ . ,ST.,WCIC- COUMTxPL~.
- _ • ~ - ' . . - . ROCER POfTR~~. . -
' - CIERK Gt~;GUt1 COi1RT . - i
• . - . . _ 4FOaR~ ~~~tED,....~~ ' j
. - . ~ ' . - . _ ~.1~. ~0 i0 48 ~Ahl'x3 ~ - i
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~ I FUR?HER CERTIFY lhat I wi{I comply with all other reyuirements~of a legal ~esident of this State.
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1 FURTHER CERTIFY that I have ~o intention to return to my former domicjle, and I intend fa remain in FORT ;
~ FIFRCE, SAINT LUCIE COUNTY, FLORlDA, permaneMly. ' ~
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! ,~''''Sw~~p.b~and subscribed E~~_:ore me this day of , ~q~ .
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ROGCR POITRAS ' ~
s ERIC CIRCUIT COUP.T Notary Public ~
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j~Y ~~`'~'e ~ _ O.C. My Commission cxpires
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; (To ue oxoculecl.in duplicale and ~~.-•~n~l tilcd wilh Clark Circuit Courf, a~~d duplicalo with Tax Assossor.j
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