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l1r.n Re~rd 3
Declaration of Domicile and Citizerlship<o:l 3. 4
') f. LUCIE COUNTY. F~~.
TO THE STATE AND COUN'i'~ TAX ASS~R,
ST. LUCIE
COUNTY. FLORIDA:
This ia m) declaration of Domicile 'lnd Citizenahip in the State of Florida that I am fili!lg this day in
accordance. and in confQrmity with Chapter 222, Section n2.17, Florida Statui,es.
I was fon.aer-~y a lesral resident QL___N ~""c.9n;t~r~t9_~u____um_h____mm'__h_mu._, hhunhm__ ._Qh;\.Q__...u_n_.
(City) (State)
and I !e8ided at.. Route _3 ..___h_.___.__.m_.________.___h_mh.____ un - --. However, I have (hanged my domicile
(Sh-eet and NUDbe.r)
to and am :>nd have been a bona fide resident of the State of Florida 5inca.6th ___h_ day of
.__.,.._..P.~_~_~.~.~~Eh.....___._._ ____..., 19_~_~__, and I reside at.___22lQ..Delawtlr.e..A.'Lenue..- ..h_._..__.__.hm____.h__
(Sb'eet and Number)
h__..~___h._.U.______.fDr~_J:)j.._~!'.~_~ h ___m___.______. _, __.. ___nhn $h.J..\i_~_i_e __.___m__________m --- ,__h County, l"orida,
(City )
and thUs statement is to be taken a8 my declaration of citizenship, actual legal residence and domicile in
the State of Florid.Ii.
(1naert here 5J1Y pertinent facta, Illcll .. ..I. of properly or bUline... or rellnQlliahment of employlJ' ant at
former domielle, removal of family to new domicile, purehue of home. .u.)
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I FURnIER CERTIY"{ th9.t I will repter at my local .tldres8 when the relPstration book! reopen,
and comply with all other requu-ements of a legal resident of tbia State.
I Fv'RTHER CERTIFY that I b.we no intention to return to my former domicile, and I intend to remain
in.-_r~~~_fJ~!'...~ e
( Clt7)
permanently.
St. L~ ~ Co +- Fl .da
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(NUM)
Vern Rehard
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(Adctleu )
Swm-n to and "ub8cri~ ~.if;4; t~.--'l1;lt,daJ of
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(TD be P:eeu~~:.'~~~'" ~ tkcl with Cklk CimU\ Court. aacI c1uplieaW wiUl Tu AaMsnr)
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