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Dp.clara~jon of Domicile Q!!d Citizenship
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'fO mE STATE AND COUNTY TAX ...;.~ESSOR,
St . Lucie
-~T. LUCIE COUNTY, FLA.'
COUNTY, FLORIDA:
This is my declarntio!l of Domicile and Citi.z.enahip in the State of Fiorida that I am ftlinir this day in
accordance, and in conform it)' with Chapter 222, Seetion 222.17, Florida Statu~.
I was formf:>rly a lea-al resident ot.___. ? l1Q.l"P!3 .b.~:rg...m.____......_______._.___._.__.., ____.Q.~.2_rg~~___._...________.
(City) (State)
..--..-----.-----. .-- '.-- . . .--. However, I have changed my domicile
Rou '.;e 1
--. -.-----..
(Street and Number)
to and am and hr.ve been a bona fide resident of the State of Florida since... 5 ___...__ day of
.....__.__~\l,gust .. ....__.., 19____qq and I reside ut----..---lJ.Ql__XQ.rk...AY~nue_________ _______:m._________.:___..
(Street and Number)
Fort P~.erce St. 1ucie r"1 .
. ..____0. .... ..------... .__....0..___.. .-....-----.--.----------------., -----.. ____.._ __ _____________...______.____.___.._..___..____ .:~. . """unty, P'londa,
(City )
ard this statement is to be taken as my declaration of citizenship, actual legal reaidence Md domicile in
the State of Florida.
and I l'eaided at
(Insert here any pertinent facts. such u .ale of property or buainua, or relinquishment of employmat at
former domicile. removal of family to new domicile, purchallt of home. etc.)
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I FURTHER CERTIFY that I will register at my local addre8s when the registration boon reopen,
and comply with all other requirements of a legal resident of this State.
I FURTHER CERTIFY tl.at I have no intention to return to my former domicile, and I intend to remain
Fort Fierce
in 'H
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~~..__.~1.l_~~.~__...__.__...____..._ .'.__.._;;;:;;;__..__m unty, F1orida,
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-ct---2J~._. . H .. __ __________.__
it' (Name)
James "i1kins Smith
. . -.. -----~---~- .-~-.- ---.-- ... - --- -.---------.-- - -_..-- ------ ..---.. -....----...-
(A.idresa) . ..
permanently.
(City)
Sworn to and subscribed before me thisu27 __ day of
i.iarch 61
__n_..___ __ .0. ......._____. .____......., A. D. 19___.__..
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(To be uecuted in duplicate and <,ririnal
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filed with Cluk Cirtult Court. and duplicate ~th Tax Auuaor)
Hor;er ?oir,r;1s, Clerk f Circui tC.;ur't
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