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Declaration-..f Domicile ~d Citizenship
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'I (I TIn: STATE AND COUNTY TAX ASSESSOR,
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ThIS IS my dedarp.tion of Domicile and Citizenship in the State uf Florida that I a<ll fil1l1j{ this day in accordance
a..d ill ."n(llrmity with Chapter 222. Section 222.17, Florida :';tatutl's,
I ',\',.5 formc'rly a legal resident of
Portsmouth
Ohio
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State
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Rt 2 Box 284
!Iuwever, I have changed my domicile
'S: rel't and ~umber)
1,' "lid ,,,0 a:1<1 hH\',l' b.'eo ;1 "lI.a ii,!(' resi,~ent of the Slate of Florida sInce
28th
day of
____~~r_~~__________n------- ,.J.~ and I reside at
4901 Oleander Lbvd
(Steet and Number)
F()HT PIEHCE, S,\l~T LUCIE COUNTY, FLORIDA,
a' ,I thi, ,tatl'n1l'll~ i, t', be taken as my declaration of citizenship, actual leK,1! residence and domicile in tbe State of Florida.
(hl'l'rt r,ere any pertinent facb, such as sale of pruperty or business, or relinqui,hment of employment
Ht ("r"'er domicile, removal c,f family to new domicle, purchase of home, etc,)
Enter:ng
Kimberly Hughes in the 1st grade
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Paule
Hughes in the 4th grade
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James Hughes in the 5tb grade
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I I'Tr~T"Ert I'LRTI! Y that I will rt'gistt'r at my local addrl'3S when tht' registration books reopen, and comply
'.,::\, oili ,th.'r requirements "f a leg"l resident of this Stute,
) FURTHER CERTIFY that I have no intention to return to my former domicile, and I intend to remain in
[-'())n' 1'll:lll'I:, S.\I:\T IXCIE COLJ:-iTY, FLORIDA, perma'lCntly.
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(Address)
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cr,. !:e tx>'culcd h duplicate and original tiled with Clerk ,Clrclllt Court, and duplicate with Tax Assessor)
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