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Declaration of Domicile anel Citizens~ip
TO TNE STATE AND COUNTY TAX ASSESSOR, 24~8£~s
.
_ COUNTY, FLORIDA: '
This is my declar~tiu~~ oF Domicilc and C'itizcnship in the State of Florida that I am fling this day in
accorJ~ncc, and in contorn~ity with Section 222.17, Florida Statutes.
.
1 was formerly a legal resident of ~ r _ and t
(c~~r) (scate>
~
n;sided at However, 1 hav~ changed my domicile to f
(Street a Number)
and am ai~d hav~ bc~rn a bo~~a fide residrnt of thz State of Florida since day ot
r
_ , 19_». and 1 r~side at a, Q-c..~~ -
- _ - t anc~Number)
~ . .~i~c.,c.~ County, Florida,
(ci~ y )
and this statement is to be taken as my declaration of citizenship, actual legal re~idence and domicile in the State
of Florida.
(Inuri hrrr any prrtinrnt facts, such u salr uf pruperty ut businrss, or relinquishment of employment at fotmer
, domicile, rrmo.al ~~f fa~ely to new domicilr, pur:hase of hume, ate.)
. ~ ~ S
-f
i~~
fILEO aHn ~~CpRDED
St_ LUCIE COUMTI' F~~. ~1
CCE KCCt~,~,CUjT COUI:t
RECORO yER~:1~0~
~ 1 2 iz PH'13
248&~~ :
1 FURTHER CERTIFY that t will registcr at my la:al address when the registration books reopen, and
comply with all other requirements of a le~al resident of this State.
I FURTHER CE I~Y that i have no intention ta return ta my former do iciie, and I intend to remain in
~ :
.
.
--~SS~!!L.__ - - > ;
~ County,
Flor+da, perma~~ently.
~ 3
e ~~A.,, ~~~~-e..~ ~ ~L
`'~jJ' •..~c. . >`r''•. - ~ ^ -
s-.; ~ ; , • ~ :
(~Jame)
' ' ' • i. 4S ~ ~ , f .
_ : ; ~ : _ M A c fc-- ~-3`a ~v
~s~ t
~ ; _ r: . ~
~ /Address)
- - ! i 1i/~as
. _
$~4orq.~A~d ;t~pscribe~ before me this ~fay of _
_C,6' , _ _ _
_ _ A.D. 19 ~sf
ROGER POi~RAS, qes' ' ~
_ . ~ - ~
~
_
_ _ ~~z~
_ - - - - S~CX PAGc " ~ .
(To be rxrcuted in duplicatr aod unginal f~led with Clerk CvcuH Court, anJ duplicate with Taz Assessor)
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