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Declaratian ot Domicile and Citizensi~ip
26181~
10 THE STATE AND COUNTY TAX ASSESSOR,
51. lUC1E ~OUNTY, FIORIDA:
This is my declaration of Domicile and Citizenship in the State of Florida that I am filing this day in attordance and
in conformity with Chapter 222, Sectio~ 222.17, Florida Statutes. .
1 was formerly a legal resident of . 1~-~~~c~.c.C.li S- C-
(Ciy) (State)
end I resided at l~ 3 `v . Nowever 1 have changed my domiCile
- (Street and Number) ~
to and am and have been a bona fide resident of the State of Florida since day of
~ _ , 19..,z-3, and I ~eside at' 2 ~ C r' ~ ~
~f! (Street and Number)
~ - /..u;~..~ , `/~r .
FOR? PIERCE, SAINT LUCIE GOUNTY, FLORIDA
and this statement is to be taken as my declaration of citizenship, actual legal"residence a~d domitile in the State of Florida.
(Inserf 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 • -
- Entering children in school :
• , • ST. l
CiE COUNTY Fl~.
ROCER POITR~S ~ '
. CLERK CIRCUIT COURt ~
/~G nr~~ ~C~t~i ~ - P.ECORD VER~FI£0~..~
`v C'~~l
, - A~ 10 li io ~M'73
~ ~ .
l ~
~ . 26181'7
{ fURTHER CERTIFY that 1 will comply with all other requirements of a legal resident of this State.
1 FURTHER CERTIFY that I have no intention to return to my former domiCile, and 1 intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. ~ ~ C/9/Y~.Be ~
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-.,5 • "o : ~ ' _ (Address) .
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~ •'~,~~~w,o~"~1~~qn~~ascribed before me this day of , 19Lbt
_ ~ f'.:GO ` . . .
~t ~tOGER POITRAS
CLERK CIRGUIT COURT Notary Public
~
.
ey _ ~ D.C. My Commission cxpires
_ ~D~K~1 I 'PACE~~25
~ (To bo exocuied in duplicate and ori~inal filed wilh Clerk Circuit Court, and duplicato with 7ax Assessor.)
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