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. Dectaration ot Domicile a~d Citizenship
TO THC STATE AND COUNTY TAX ASSCSSOR, 262896
51. lUC1E COUNI Y, FIORIDA:
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lhis is my decla~ation of Uomicile and Citizei~ship in the State of Florida that I am filing this day in accordance and
in conformity with Chapter 222, Seclion 222.17, Florida Statutes. ~
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l~GC~.wa-~oSa. 1..1~schr~s~ r. i
I was forme~iy a legal resident of
(C~~y) (State)
and I resided at _ ~S~z /'~Ocuc~ i` GOU rT However I have changed my domic.ile
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to and am and have been a bona fide resident of the State of Florida since _ t~' ` ( S~ day of
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~ ` , 19
7-3 , and I reside ~at • ~S 7Z 5 . E Su?? S ~ ~ ~1t ~
(Street and Number) ~
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FORT F~IERCE, SAINT LUCIE COUNTY, FLORIDA
and this statement is to be taken as my declaration of citizenship, act~af legal residence and domicile in the State of Florida. ;
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(Insert here any pertinent facts, such as sale of property or business, or relinquishment of employment s
at former domicile, removal of family to new domicile, purchase of home, etc.) ~
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Applying, for Homestead • -
- Entering children in school : ~
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' OCER POITRAS
C~ERK CirCU1T COURT
RE~4RD YfRIf1ED
~ S~r 5 12 03 PH '73 ;
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~ 262896 ~
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1 FUR7HER CERTIFY that I will comply with all other requirements of a legal resident of this State, z
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I FURTHER CERTIFY that I have no intention to return to my former domi~ile, and I intend to remain in FORT ~
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PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. ~ E
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R. ' ~ ` ~ (Name)
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~~:Y j° W;~'',: ~
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•1'~ " l;~ ~ L~%.~~ - IS 72 S E. S~,. r. s~ t~ ~v t.
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Sworn to and~"subsc~ibed before me this day of ' , 19_1s~.
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ROGCR POITRAS '
~ CLERK CIRCUIT COURT Nofary Public `
1~ E.y _ _ D.C. My Commission cx~ires ~
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~ R 2~.g PAGE 775 . ~
BOOK ,
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(To bo oxecuted in duplicafe and oriyinal filed with Clerk Circuit Court, and duplicalo with Tax Assessor.) #
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