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'f0'T11L• STATI: ANU C:OUN7'Y TAX ASSI~SSOit,
ST. LUCI~ _ GpUi~'fY;1~LOltIDA: ~ 2619~6 ~ - • ~
Tliis is my dcclaration of Domicilc and Citizen.hir in thc Statc of Florida ihat 1 ai» filinF this day in
accordancc, and in confon»ity witl~ Scction 22.17. Floricia tatutcs. .
I was fornierly a Icgal residcnt oC , ~ and I;.
j~ ~l~ ' `~`r) (sute)
resided at o~DOt- . Howcvcr, I have ci~an~;cd my domicilc to
~ (Slteet and Number)
an am and liave becn a bona fide resident of tl~e State of Clorida since a~~ day of
~ , 19 ~ and I residc "at ~o~ ~ ~ ~ ~y
(Slreel and Number)
~~.e~ ~ ST LUCIE _ County, Florida,
(cacr)
and this statement is to be taken as my declaration of citizenship, actual iegal residence and domicile in the State
of rlorida. ~ •
(Inseri hete any pertinent facls. such ss sale of property or business. or rclinquishmcnt of emploYn?cnt at tormer ~
domicile. removsl of family lo new domicile. purchase of home, etc.)
- ~ ~ . - ~
Applying for homestead: . .
~ Enterin children in sc.lool a.~ ~
~ g ~
~ Other: ~ - - - . .
- FIlEO AKv REC~RpED f
~ ST: LUC1C COUKTY FE~- ~
j ~ : ROCER P~?TRAS ~ . . .
; _ Ct6AK ~3F:CUtT CQURT ~
i . . . • RfC~R~ VERiflfO .
€ . - ~ . p~c 1t .12 3s PN'~3-
. 261926 . . ~
; . ~ .
I FURTIiER CERTIFY that I will rcgistcr at my lacal address when tl~c rcgistration books rcopcn, and
comply with all othcr rcquiremcnts of a Icgal residcnt of this State.
I F RTHCR CERTIFY tliat I have no intention to return to my former domicile, and I intend to rcmain in
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, P~~ S t~. Luc ie , County,
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~ rlori ~~e~~g.r~~ly. ,
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,$~i~'t~'rriiT ~~ribcd bcforc mc this day of
'~•r. Et?C p~.,~ .
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lt(~GT:R POI'1'It/1S, CLi:ltl: CT]ZCUI~ cou1;T eeoK~G17 PAGE~~
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