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Declaration ot Domicile a~d Citizenship
TO THE STATE AND COUNTY TAX ASSESSOR,
261835
Sl. LUCIE COUNTY, fLORIDA: .
This is my declaration of Oomicile and Citizenship in the State of Florida that 1 am tiling this day in accordance and
in contormity with Chapte~ 222. Section 222.17, Florida Statutes.
1 was former{y a legal resident of . Ver
(City) (Sfate)
and I~esided at . However 1 have changed my domitile
(Street and Number)
to and am and have been a bona fide resident of ihe State of Florida since day of
~ , 19~., and I reside ~at y s 3/ ~ S~ ~
(Street and Numbe~)
c
fORT PIERCE, SAINT LUCIE COUNTY, FLORIDA ~
and this stateme~t is to be taken as my declaration of citizenship, actual legal ~esidence and domicile in ihe State of Florida.
(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.) "
n Applying~ for Homestead _ • -
- ~tering chfldren in school : -
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ROCfit POIT~A~ ~
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~ ~ 261835
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I FURTHER CERTIFY that 1 will comply with all other requirements of a legal resident of this State.
I FURTHER CERTIFY that 1 have no intention to return to my former domiGile, and 1 intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. ~
. . ~ ~ ~ .
. (Name)
U ~ T .
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,''~,G~S~i~torn.td ar~v~3cribed before me this v day of _ . , 19~•
a, ~ -
~rre?rt~t~+'~~~ •
•~f ~y . .
ROGER POITRAS
CLERK CIRCUIT COURT Notary Public
! ~ ~
ny _ . Yl~ V~ «-~'t~ D.C. My Commission expires
do~2'17-~2249
~
- (To bo oxecuted in duplicato and original filed with Clerk Circuit Court, and duplicato with Tax Asseswr.)
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