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D~cfaratioc~ 04 ~omicile a~d Cittzert~hip ~
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TO THE STATE AND COUNTY TAX ASSES50R, << C1rl ~
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Sl. IUCiE COUNi'Y, FLORIDA: ~
This is my declaration of Domicile and Citizenship in the State of Florida that 1 am filing this day in accordance and
in conformity with Chapter 222, Section 222.17, Florida Statutes. i
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( was formerly a lega) resideni of _ ~~leWOOd_ , _ ~ . T1eW ersey j
(Cityj (Siafe) J
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275 Gra»d Ave.
and 1 resided at _ - _ _ - . However I have chanc~ed my domiGile ~
iStreei and Number)
to and am and have been a bona fide resident of the State of Florida since .______19th day of i
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November__ 19__ 65 and I reside ar _ 855_?~irosa__Blvd
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FORT PIERCE, SAINT LUCIE COUNtY, ~LORIDA j
and this statement is to be taken as my declaration of citizenship, actuat tegat residence and domicile in the State of Florida.
" (Insert here any pertinent facts, such as sale of property or business, or relinquishment of employment ~
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at former domicile, removai of family to new domicile, purchase of home, etc.)
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Applying for homestead FtLED
N ECO DED
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` ~ 66JAN2 p I•y8 ~
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, ; ~ ROGER PO~~rR ~
- N~' ~ ~ . ~ ~ ST. LUCIE COUNTYR~ . -
,'\i•~ •v7. .1~' FL.ORIDA
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I FURTHER CERTfFY that I wili comply with all other requirements of a legal resident of ihis State. ~
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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 ~
PIERCE, SAiNT LUCIE COi1NTY, FLORIDA, permanently_ ^ ~
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...Svtiprn~to and subscribed before me ihis 25tb? day of ~Tan__a~ , 19^.~j6
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ROGER POITRAS
RK CIRCUIT COURT Notary Public
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By D.C. My Commission expires
(To be executed in d~splicste and original filed with ~lerk Ci~cuit Court, and .'uplicate with Yax Assessor.)
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