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Declaration of Domicile and Cifizcnshs~~
TU 1'III: STATI: ANU COUN1'Y "1'AX ASSI~:SSUR, . 2650~0
SC.Lucie
- coun~rY, LORIUA:
Tl~is is my dcciaration uf Uomicilr anJ ('itir.rntihi~~ in the Statc of ~lorida that ! am liling this day in
accordancr, .ind in conformity with Scction ''22.17, Flori~la Statutrs.
, ~lit '
1 was fornierly a Icgal residrnt of ~,,c~/Ll~~~.. _ and 1
(citr) (s~a~r)
resided at s~~f2!_~~~ es~~~"~,~ . Nowever, I have changed my domicile to •
~ (Street and umber) ~
and am and havc bcen a bona fidc residcnt of thc Statc of Florida since _ day ot ~
now ~
, 19_..~__~_, and 1 /~reside at _.,~~~..,z S C ~ ~ #
Street and Number) }
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I, , St. Lucie County, Florida, ;
(City) ;
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State
of Florida. ~
(Insert hcre any pertinent facts, such u sale of property or business, or rrlinquisAment of employment at formet ~
domicile, removal ot tamily to new domicile, purchax ot home, ete_) ~
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Entering children in school: . ~
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FILEO ~H~ RECORDE~
~ ST. LUC+~ COUNTY flA. ~
ROCEP PO~IRAS ~
CIERK Ct~;CL'IT COURT
~ RECORO VEFIf1ED
~~.~-~.e~. in~ OeT 3 II 39 AH'73
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I FURTHER CERTIFY that [ 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 t~ave no intention to return to my former domicile, and I intend to remain in
~ - b~~ S~ . Lucie , CountY,
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Florida, perman tly. cc~'r~ ~ ~i~-~~
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_ ~ • {t "r~ (Address) -
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~ Sw6t~rj'~t~~rk{ su d beforc mr this day of
~
z.. ~ 4 • 1 .r` ~C
7_~- A.n. 19____73_.
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ROGER POITRAS, CLERK CIRCUIT COURT -
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(To be executcJ in duplicrtr anJ urigm~l fdr ~v~lh l"la•rA C'ircu~t ('uurl. anJ Jupli: atc w~~lh laa Assc.~ur)
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