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Declaration of Domicile and. Citiienshi}~ '~s
TO THt: STAT ' ND COUNTY TAX ASSESSOR, '
t _ COUNTY,,FLOR1llA: ~
Ti~is is my dcclaration af Domicilc and Citizenship in th~ State of Florida that 1 am filing this day in
accordance, and in conformity with Section 222.17, Florida Statutes.
I was formerly a legal resident of ~?A~1 SV! ~e.F' ~D f9~19 and I
(Citr1 ~ (Ststej
resided at ~r~'~ t. C fIE'lL2 Y S~' . However, I have changed my domicile to
(Street and Number)
and am and have been a bona fide resident of the State of Florida since day of
~e
G 19~z_.., and 1 reside at ZC-Z Cf7~.MG SR ~/~l d~''
~ ~ (Sireet and NumMr)
~T ~IEXcF' , S`T ~uci~ County, Florida,
(c~~r>
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State
of Florida.
(Insert hae any pcrtinent facts, such ss sale of property or business, or relinquishment of employment at totmer
. domicik, remoral ot fsmily to new domicile, purchax ot home. ete.)
Applying for homestead
Entering children in school :t~
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' F~~Ea akD RECORpEp
ST. IUCIE
' ~~J CLE ,COUNTI? f~A.
! E., r01tQ~5
I REC~RD Y at `'UIT CQURt ~
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~ 1 FURTHER 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 1 have no intention to return to my former domicile, and I intend to remain in
~ ~ Si. Luc't~'
~ FT. r~/~C~- , County,
~ Fforida, pcrmanently. G 1~w?v Cli r~; s~ ra~~
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~ (Name)
s.~ ~2 CA~MoS~g 17R~V~
F;~ : , (Address)
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Swi~r~~~nd ~y~.'~bed beforc mc this ~ day of •
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~ ' •~,f~ .D. 19_?
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