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ST. L 1 pU,MT1~ FLA.
Declaration of Domicile on~ ~it~zenship
TO THE STATE AND COUNTY TAX A33E.gSOR,
3t. Luo i e COUNTY, FL08IDA:
This is my declaration of Domicile and l3itizenahip in the State of Florida that I am filing *.his day in
accordance. and in conformity with Chapter 222, Section 222.17, Florida Statutes.
I waA fnrlnel-ly a legal resident of----------'~'~.I~eO~------------------------------ ----- ~~.Org18-------------------
(Cft~) (State)
and I resided at--_514 -.YOpiar______-- -- - ---------------------------- _-_-- __---- However, I have changed my d~~mirue
_ -_- -
(atreet .nd Nnmbar) 17 t h
tc and ant and ha.e ?;sen a bcra !ode resident of the State of >•'loridR since _-.---. day of
AC~!~ N= 4th St .-_--
De4ember-------------- - - ----- 1S_d-----, and I reside p~-----_--- _-------_- - - - ----
------------------------------ -- - -
- --- (Street and Number)
Fort Pieroe _ _-
St.Lucie
___--County, Florida,
(City)
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in
the State of Florida.
(Insert here any pertinent facts, sucl- as sale of roperty or buau,e~ .'or~nlin9uishment of employment at
former domicile. removal of family to nsw domicile, purchase
e ,. _~__,
~lilir~; ia,ja viia CiYl iii 1l`a yYYi~~i oi.:.v v+.
915~L:3
1- Johnny 1Nlilliem Clements t
F~CF~ ,1~" RECDRJED
~JJi
;. ;~;. ~ POITRkS. ~l'~
S;. LUCK COUNTY, fLC~...:~ ~/
- ,.~• !.
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T T~ TTjt~_ ~+,R ('-~+,R'l`ii~`Y t~~ I will reclater at Tssv local addrzss when the rsist~-ation books reopen,
and rnmply with all other req_uiremente of s legal resident o! this State.
I FURTHER CERTIFY that I have no intention to return to ~- former domicile, and I intend to remain
~ Port_Pi era s _ - ~ St . Luo ie __-__~ty, Florida,
pe:'maneatlY
' ----
(Nara)
LOIIn1e !"ar~et
- -, (Addrraa)
Sworn 'to and subscri~~:a~{i'~l~ -dy of
~:. .,r - ,
.,
otsry
Coaamission P+• i'eri~!~i!G'r- ' `~-' ' i~ ~~,~~ec
.e1~t..I tbloa wwi Cioek CiKOIt coast. ass dapaate wit>b- ~ e,oa..or)
(Te bo ez.eaad la donisa.w ':ad-~
~te...w 6aoDb Cs.. Plant C1t7. Tin.