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Deciaration of Domici~e and Cif izenship ~
TU TI~E STATE AND C.OUN'I'Y TAX ASSGSSOR, 254295
St.Lucie ~OUNTY, FLORlUA: ~
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71iis is my dcclaration of Uomicilc ~nd Citizciiship in thc Statc of Florida tl~at 1 am filing this day in
accordance, and in confotmity with Section 222.17, Florida Statutes.
.
1 was foc~er,ly a legal resident of ~G%+U~ ty~~ , Q~"v and I
resided at . However, 1 have changed my domicite to
(Slreet and Number) ~t
and~ am and have- been a bona ficle --resicient~ of - the • State ~ of ,Flotida since , °2~ - day- of
now
, 19 73 y and 1/resid~ at `~3~ G~~t~;
treet and Number)
~ 11 . S t. LuC ie County, Florida,
(ci~r)
and this statement is to be taken as my declaration of citizenship, actual legat residence and domicile in the State
of Florida. ~
(inserf he~e any pertinent facts, such ss sale of property or business, or telinquishment of emplorment at formu
domicile. remoral ot family to new domicile, purchase ot home, ete.)
Entering children in school:
%~~lPh~d~fi~
, C~~~/
FILED At10 R~CORDE~
SL lUC1E C~UH7Y FIA,
ROS~r ?aITR~S ~
. . ClE~~C C~?;,ii:T C~URT
RFr,n(;.~ 1_~~=~EJ
_ SEP 7~ 10 20 ~'I '73
~ ~ 264~95
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I 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
~ ~p-~,~f= ~.G~ Cu2, St . Lucie
~ , County,
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x
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~ • ~~G lI 1 r = (Name)
..~uM:~~C~',, .
A ti • ~ -
°r ~ G~ ~ ~y -
~ t ' r '
? r ~I (Addre )
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~ Ni:, + c C ~1•.,,:~
~ ~ t,~ .subsCr e~eforr me this ~ day of
~ s; ~
~ ; ; w~.~°~ .
,G..~. . v. i 73
n. n. _
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~ R~~,~~~T~AS, C RK CIRCUIT COURT .
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~ (To lx e:eculeJ in dupl~alr auJ ~~riginal ti • wi~l~ ('Ir~k ('ircuil Cuurl. and JuplKate wilh Tax Asseuot)
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