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Declaration of Domicile and Citiienship
TU Ttit: STATE AI~U COUNTY TAX ASSESSOR, `
~4ss ;
, `
~ COUNTY, FLORIDA:
This is my declar:~lion of Domicile and Citizenship in the State o` Floricia ihat I a~~i ~liiig ihis day in ~
~ccordanc~, und in conformity with Secteon 222.17, Florida Statutes. ~
i
1 was formerly a legal resident of _'__NEW
~
c1..~n1 E/~1~ A^ and I `
~
(c~~r) (siace~ ~
r~sid~d at ~e [ra? r ~ a, R~~2 . However, I have changed my domicile to ~
(3treet and Number
a»d am and have bccn a bon~ f3de resid~nt of the State of Florida since ~ 3 day of
, 192~., and 1 reside at ~EM~ /~A~Bee~ l'~,~ e%
~ ~~iCAi . - ~ a 4 ~e `c ~(is
A Jt a tvumber)
F~L_ _ ~RC ~ _ . County, Florida,
(c:~y~>
a~id this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in S;~*_P
uf Florida. ~
(Inseri here any pertinnnt facts, such ss sate of property or business, or retinquishment of employment at tormer
domicile, removal of family to neM• domicite, putchase of home, rtc.)
~IC1119R1~ ~~NESM I T~f
FILfD ANO RECOADEO
3T. LUCIE COUNTY fLA.
ROCfR rOt7RAS
CLERK Ct^CUtT COURT
RECORQ YEr~.'FIEU~J~
M~r ts 10 ~2 AM'71
~456
j I FURTHER CERTIFY that I will reg,ister at my local address when the registration books reopen, and
~omply with all other requirements of a legal resident of this State.
i
~ 1 FURTHER CERT[FY that t have no intention to return to my former domicile, and I intend to remain in i
` i ~ OI ERC ~
- f E . , County, ;
' Florida, permane~~tly. «''y~ ~
~
~
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r. , a .
(Namei
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(Aa ess) ?
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; Sworn to an subscribed before me this day of
~
~ . ~ _ . A.D. 9
i N y~,,,,~ -
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. ;9~: i1a~ Public State ot rida at LarRe ~~K~~ ~rr~o~~
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's DMI~.,-Comr~ussioti~e$pires ~ - /G ' ~3
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~To be executed in duplicate and original fded with Clerk C'vcuit Court. and duplicate with Tax Axsessot)
AGU fnrm 'i
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