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'f0 '!~1 f G STA'1'1: ANI) C'UUn7'Y TAX ASSI :SSOR; ~4~ ~
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ST. LU.CII: ~C'OUN'CY; I~LOItIDA: ~ ~ ~
'fliis is m~~ dccL•~ration of Dc~micilc and Citizcnship in thc Statc of Florida that 1 am filing this day in
accordancc, xnd in confarmity with Section 222.17 F orida Statutcs. , ,
I was fonncrl a 1 al resident of r~ ~ and I
/ i ~ ,~1~~~~r ?'ta, (ci~Y) (stace)
resided at , ~ . Howcvcr, I l~avc changcd my domicilc to
(Street and Number) /
and an and havc becn a bona fide residcnt of thc State, ~f ~lorida since ~1~.-- day of
73 ~~Dl ffa ~~'o~~~-
, 19-_, and I residc at .
,Q ~t and iiumbrt)
/ (JuraC , ST LUGTE County, Florida, -
(cicr)
and this statement is to be taken as my declaration of citizenship, actuai legal residence and domicile in the State
of rlorida. ~ ~ -
(lnsert here any pertine~t facts. such as sale of properly or business, or relinquishment of employment at former
domic~l~. removal of family to new domicite. purchase of home, etc.)
' ~
Applying for homestead : . , ~
- - ~ Entering children in sc~zool : ~ ~ ~J . -
Other: ~ . - ~ - ~ - . .
~ . " f1~E~ Al10 RE~ . -
i - ~ • ~t_ «rctE c,~t,~, . .
t - , . 6t R~CfR POIT1twf~.
F - _ - RECORO VER~~~~t .
~ . _ F.~£~...~,~ ~
- . - - - ~ ~ ~ 11 ~ ~1 ~iI'l3 .
- - ~ 26204{3 ~ - ~
I rURTI1L'R CERTIFY that I will rcgister at my local address when the registration books reopen, and
comply with all other rcquiremcnts of a lcgal resident of this State.
1 FURTIILR CCRTIT'Y that I have no intention to return to my former domicile, and I intcnd to remain in
, i'w,r,~ St . Lucie , County,
~ `
(c~~r) ~-~"d 1. rv t~t . R; I e
~ Florida, pcnnancntly. ~ ~ ~ `t Tw ~
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- / (Name)
+ ~
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_w ~ ` ~waa«s.~
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SvNQiY~to.~r h~ ~c~ Ucforc ii~c this 2- day oC ~
• Y • - [~I _
n.n. ~ ~
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I:OC'I:IZ POT7'1tAS, CLI;RK Crl CUTT COU1t1' 0 R z~? PAGE~JV
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