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Declaratiorr o1 Dor~nicile and Citlzenship
TO THE STA1'E ANO COUNTY TAX ASSESSOR,
Sl. LUCIE COUNTY, FLORIDA~
This is my declaration of Dom;cile and Cit~zenship in the 5tate of Florida that I am filing this day in actnrde~ce and
. in tonformify with Chapter 222, Section 222.17, Florida Statutes.
I was formerly a legal resident af ~u11~8D A18bi~i
(Ci+y) (State)
and I resided ao _ 401 _ N~ 5th_ AVt._ E_ . However I have changed my domic,ile
(Street and Number)
to and am and have been a bona fide resident of the State of Florida since 'z31d day of
August _ 19 6$ , and I~es~de at 1009_ Flood_R White Cit
treet and Number) ~ ~
~ORT PIERCE, SAiNT LUCIE COUNTY, FLORIDA
and this statement is to be taken as my declaratian of citizenship, actual legal residence and domicile in the 5tate of Florida.
(fnsert here any pertinent facts, such as sale of property ar business, or relinquishment of employment
at fo!mer domicile, removal of family to new domicile, purchase of home, etc.)
Entering Criildr~n in School
FtL ~?jVp EC6R~E~
ir1.___ L ~voK
'65 A4J~ 3 Q PM I: 5 y
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- , _ ~ _ . . . . •
, _ . ROGEr; : i;; CLERK ~
" ST. LUCIE COUNTY,
- FLORI~A
. . _ _
~ , 5
. ~ ~ J ~ ,
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I FURTHER CERTIFY that I will comply with all other requirements of a legal resident of this 5tate.
I FUR7HER CERTIFY ihat I have no intention to return to my forner domi~ile, and I intend to remain in FOR7
PIERCE, SAINT.lt1C1E C~UNIY, FLORIDA, permanently.
. , . . ~.i -.i ` o` . :
~ - Jesse S. B~abage
~ - -
' ' . ' 6~ ~ ^ (Name)
3 ~ ~ . ' ~ ~ ~~.~,~,1
.
`
(Address)
Swom to anc~ subscribed before me this ___30th day a{ __,_____A~~g~ _ , 19_._.~,~.
ROGER POITRAS ~
CLERK CIRCU~T COURT Notary Public
, ~
~Y `f--=~~~ ~ ----(.,.G4'__~~`' b.C. My Commission expires ~
(To be sxecutsd in duplicate and origiaal filed with Cl~rk Cirtuit Court, snd duplisats with Tax As~es~o~J
n~U,~25 4~
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