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Deciaration o~ Domicile and Citii..~nship ;
TO Tt1E STATG ANU COUNTY TAX ASSL:SSOR, 264~9~
St.Lucie
COUN'1'Y, FLORIDA:
Tl~is is my dcclaration of Domic:ilc and Citi•r.cnship in the Statc of Florida that 1 am filing this day in
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accordanc~, and in conformity witli Section 222.17, Florida Statutes.
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I was formerly a Iegal resident of -~~z-C~c C„ , A•~-~A and 1 ~
(city) tstace)
msided at ~=4~- . However, I have changed my domicile to
rm-sa (Sl~eel and Numbet)
and am- and hsve been a bona fde resident of' the State of Florida since ..e~ day of
_ .
riOW - ~ .i /G~~ ~ . . _ . _
- , 19~ and 1 /Ecside at
~~G ~ ~f (Street and NumEer) .
~ ~ . St. Lucie County, Fiorida,
- (c~~r) ~Z~c_ .~r,~u.
and this statement is-to be taken as my declaration of citizenship, actual legal residence and domicile in the State
of Florida. '
(Inseri here any pertinent facts, such u ule of pro{xrty or bustness, or ~elinquishment ot tmploymmt at former
domic~e. temovsl ot family to new domicile. purchase of home, ete.)
Entering children in school:
7~i~~ 7,r~~
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~ I FURTHER CERTIFY that I will register at my local address when the registration books reopen, and
comply with all bther requirements of a Iegal resident of this State.
I FU HCR CERTIFY that I have no intention to return to my former domicile, and I intend to remain in
t ~,~,t St . Lucie Count
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, Fto~da,~ t;manently. cc'`''~
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_ ~ :,o~'.. k'~~r~•• % ' - ~
r,:. j~~' _ i'~ (Name)
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Sryij ~~~~~~bscribcd before me this __1- day of ~J r- /q ,
~ G~ ~ ~.C~ ~i.~.~- i
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~ , A.D. 19-73_.
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~ ROGER POITRAS, CLERK CIRCUIT COURT - .
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(Tu be eaeculed IIU~~IICdif JIIIi Ufl~~n~.~ ~Icd .+ith t'lerk (tircuit Courl.:md Juplicale wilh Tax As~eswr) .
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