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Declaration of Domicile anc~ Citizenship
"t0 TH~: STAT ~,ANU COUNTY TA~ ASSk-.SSOR. 245943
~
COUNTY, F=LURIDA:
Tl~i~ is my d~claratiun c~t' Domicil~ ;~nd Citircnship in the Stat~ of Florida that I am filing this day in
~i~cor~lance, .ind in conformity with Sectiu:~ _'?_'.17, Florida Statutes.
! was formerly a legal resid~nt of . - - - -r-------- . --f~PGI/ I-~ _ and I
(C'ity) (State
r~sidc:d at tC~.1 C_~~~_ _ . However, 1 have changed my domicile to
~
(Strert and Numbrr)
,ind am and have brcn a bona tidr rrsidrnt of thr State of Florida since
. 19_-~~_ :~na 1 reside at ~ -
• treet an umbe{)
9 ~!r , ~f;
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f--- _ ti
u ~L, - County, Florida,
~citY)
and this statement is to be taken as my derlaration oi~ citizenship, actual Iegal residence and domicile in the State
ot Florida.
Qnxr. here any pertinrnt tacts, such as s:~lr of property or businrss, or relinyuishmnnt of employment at former +
domicile, remuval of family to nr~v domicilt, purch:tsr of home, rtcJ i
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~ILfO A~Vn RE~
ST. LUCIE CdUkT~~
CLE KCG~sC~jTCOURT ~
RECORC VCP,I~~Ep~
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I f'URTHER CERTIFI' that l will register at my I~cal address when the ngistration boohs reopen, and
~ romply with all other requirements of a legal resident of this State_
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~ 1 FURTHER TIFY that I hav~ nc~ int~ntion to return to my fornier domicil~.,.~and I intend to remain in
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g - ~ County,
- - - _ - - - - - - - .
~ Florida, perman~ntly. ~c-"•~ -
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(Name)
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; ' ~ '.i~ :;'1.,, _ - - ~~aa~z~s?
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Sw~o~•fo and subn;~~sd befor~ m~ thi: C~ ~lay of~
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' Y. ttOc State nf I Inri a t.aree
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A-iy Conirttission espires_ _ - - / 6 ~ _ -
~ (To br r~ecut~d in duplicatr and nnfin.il f~lyd ~~ith ('Irrk ('~rcuit Cnurt. and duplicate with Tax Asses.wrl
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