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Deciarat~on of Domicil~ and Citizenship ~
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TO TNE STATE ANU COUNTY TAX ASSL:SSOR, .
st . Luc ~e 264~96
~ _ COUNTY, FLOKtUA: ~
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Tliis is my deciaration of Domiciic and Cititcnship in the Statc of Florida that 1 am filing this day in
accordance, and in conformity with Section 222.17, Florida Statutes.
, • ¢t~o f ' ~ / ~ . ;
I was formerly a lcgal rts~dent of T_ , and 1
(cilr) (S1ste)
resided at ~~Q~ ~/2.~~-'
~Z
~ . However, I have changed my domicile to
~ (Street and Number)
and am and_.have _ b~:en_ a bona fide _ resident of the State of_ Fiorida sinc_ , day_ of
now
, 19_~~ and I /~cside at - -
~ . (Street and Number)
j~~~ ~ St . Lucie County, Florida, E
(~~r) '
t
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State ;
of Florida. ~
(Inxrt Aere any pertinent fxts, sueA as sale of property w businas, or ~eli~quis6ment of employment at fotmer ~
domicile. temoval oi family to new domicile, purchase of home, etc.) ;
Entering children in school:
l~/~ `f~ ' ST
L
C E COUNTY FLA. S~
R6GE= ?'v~?RAS
CIERK ~~'=CUtT C~URT
L ~ ~ ~ ~ ' L ~ Rc~r~R? Yi =:~~IE~
s~P 7~ ~a 28 a~ ~73
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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 CERTIF at I have no intention to return to my former domicile, and I intend to remain in
' ~ ~ S~ . Lucie Count
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F (ci~r) ( w E Rs
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\ y"~~(e~ ~ ,,9 ~.c~-i/
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` ' '°,U Jl~f ~ O ; f; (Name)
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~ ~ ~~'v;c, • ° • " _ (Add~ess) ~ /
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~ SvV6y~i. . A beforc mc this -2~ day of
~ n,c.....::;:'-.~~';:' ~
~ ` ~ C0 • i ,ti`~ ~'~Y p / . A.D. 19_73
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_ ROGER POITRAS, CIEBK CIRCUIT COURT ~ .
~
. __..r..~~.. _ ~ ~ a00K~v ~!1(~~~ 1~
De u y 'Cler
(To be execuled in duplicale ~nd ~~n~;inrt fileJ th Clrr~. Circuif Coutt, and duplicate Nilh Tax Assessor)
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