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DECLARATION OF DOMICILE AND CITIZENSHIP
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, TO THE STATE AND COUNl'Y TAX ASSESSOR,
ST. LUCIE COUN'I'Y, FLORIUA
This is my declaration of Domicile and Citizenship in
the State of Florida that I am filing this day in accordance and
in conformity wi~h Chapter 20412 Laws of Florida, Acts of 1941.
I was formerly a legal resident of New York City, New
York and_I resided at 303 East 57th Street. However, I have
changed my domicile to and am and have been a bona fide resident
of the State of Florida since January 2, 1971, and I reside at
3024 S.E. Santa Anita Street, Port St. Lucie, St. Lucie County,
Florida, and this statement is to be taken as my declaration of
citi~enship, actual legal residence and domicile in the State of
Florida.
I F'URTHER CERTIFY that I will register at my local
address when the registration books reopen, and comply with all
' other requirements of a legal resident of this State.
I FURTHER CERTIFY that I have no present intention to
reestablish my former domicile and I intend to remain a legal
resident of and domicile in Port St. Lucie, St. Lucie County,
Florida. .
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, #~~:`f~~~; z,~•~ ~i1c'~'~~.,;=' KEITH CLARK
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ary lic State o lorida at Large '2 0 8 0 4 S
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