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Oeclaratio~ ot Domicile and Cittzensh~p
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TO THE STATE AND COUNTY TAX ASSESSOR. `
1
51. IUCIE COUNTY, F~oR~uA: ~ 261630 1
This is my declaration of Domicile and Citizenship in the State of Florida that I am filing this day in acco~dance and
in conformity wilh Chapter 222, Scction 222.17, Florida Statutes. .
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I was formerly a legal resident of ~r~~
. (Ciy) ~ (State)
and I resided at _.L~ ~ . However 1 have changed my domiCile
• (Street and Number) -
to and am and have been a bona fide resident of the State of Florida since ~ Z~ day of
' , 19~, and I reside ~at • 7~~ ~f'
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
and this statement is to be taken as my declaration of citizenship, actual (egal residence and domitile in the State of Flotida.
(Insert here any pertinent facts. such as sale of property or business, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
Applying~ for Homestead . -
- Enterinq children in school :
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- ' iT. ROCER
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~ CI.ERK CiRCU1T COURT ~
~ ' REQ0110 Y!!UI![0...~...~
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. 261630 . ~
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1 FURTHER CERTIFY that 1 will comply with all other requireme~is of a legal resident of this State.
I FURTHER CERTIFY that I have no intention to return to my former domiG~e, and I intend to remain in FORT
PIEf<CE, SAINT LUCIE COUNTY, FLORIDA, permanently. ~ o~~ c~ ~
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SwQtM•1watlt~~ subscribed before m this ~ 7 day of , 19~
.
ROGER POITRAS .
CLERK CIRCUIT COURT Notary Public
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(3y D.C. My Commission expires
a~aK 217 PAGf 19~?
- (To be oxocutecl in duplicato and original filed wilh Clerk Circuit CouN, and duplicato wilh Tax Assessor.) -
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