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Declarat~on Q~ Domic~~e ar~d Citizen5~ip
"f0 THE STATI: AND COUNTY "t~AX ASSI~SSOR,
st . Luc ~e 264466
COUN7'Y, LORIDA:
Tt~is is niy dcclaration of Donticilc and Citircnship in thc State of Florida that 1 am (iling this day in
accordancc, and in confannity witl~ Scrlion ~22.1 Florida Statutcs.
1 was farmcrly a lcgal resident of O O D~ 9~ ~ ~ 1_ and 1 ;
lc~~r) (sea~e)
resided at ~ 6~L~ ~ A~ ~~?~¢y__ 1~_!F' . However, 1 have changed my domicile to
(St~ert and NumbT
and am and have bcen a bana fide ilSl(It'll[ of the State of Florida since day of
now
1 ~ ~ ~ , 19_ ~ ~ and 1 /~esidc at ~ 4~ _~9 ~ ~ /?J
(Street and Numbet)
R~- L T v~ . St. Lucie County, Florida,
(citr)
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State
of Florida. •
(lnseri here any perlinent facts, such as sale ot property or business, or relinq~~ishment of emploYment at tormer
domicJe. removal ot family to new domicile, purchase of home, etc.) .
t
Entering children in school:
.1~m ~5 Kr L L~ m.5
f1tE0 A~? 4t~UR0E0 ~
ST. ttiC~i :,JUNiY ~LA.
RGC~~ FO!TRAS
CLERR Ct~:CUtT CCURT
RrCO~?' VEN!FIEp
~ ~ SEP 16 10 2~ AH'73
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~ 2s4466
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~ I FURTHER CERTIFY that I will register at my local address when the registration books reopen, and
g comply with ali other requirements of a legal resident of this State.
~ I FURTHER CERTIFY that ! havc no intention to return to my former domicile, and 1 intend to remain in
~ ~ .;',~,1. ~ ~ C S*. . Lucie County,
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Flar,,~ ,~,~~,~eatly. ~c'~r~ - C . ~ ~ ( t- e w e~
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~ ' _ Y. (Nsme)
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. ~ ~ (Address)
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SWAiF#Ctcxan~~bscribed bet'ore me this Jay of
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` S e ~T , A.n. ~~73__
~ ROGER POITRAS, CI.ERK CIRCUIT COURT .
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y~ 15eputy CIe .
(To be e~rcuteJ in duplicalr and ~~ri~~~n.~l drd ~~~t6 /'Irrl. C~rcuit Courl. •rnJ duplicalr with Tat A.ssessor) , .
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