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Declaration of Domicile and Citizenship
TO TNL' STATE ANI) CUUNTY TAX ASSI~SSOR,
^ St.Lucie _COUNTY, FLORIDA:
This is my declaration of Uomicilc and Citizrnship in the Statc of Florida that I am filing this day in
accordance, and in conformity with Section 222.17, Florida Statutes.
I was formerly a legal resident of ~ /G~' - and i
~ citr) (st.te>
resided at ~ . However, I have changed my domicile to
(Sireet snd Number)
and am and have bcen a bona fide resident of the State of Florida since l~~ ~ day of
now
, 19_____~ and I/Eeside at ~o~ai ~~5~ l
c ( treet and Tiumber)
, St. Lucie County, Florida,
~c~~r)
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State
of Florida. -
(Inse~i here any pe~tinent facts, such as sale of property or business, or relinquishment of employment at fotmer
domlcile, removal of family to new domicile, purchase of home, etc.)
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RECOR~ YE~:c~~p
~ oi'~ Oct t0 I 39 PM'73
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~ I FURTHER CERTIFY that I will register at my loca! address when the registration books reopen, and
comply with all other requirements of a legal resident of this State. .
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~ I FURTHER CERTIFY that I have no intention to return to my former domicile, and I intend to remain in
~ " St . Lucie County,
~ Florida, permanently. «''y~ ~
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S~~o"t~x~tq•~ su}is~d~iefore me this day of
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- I~~' - A.D.19 73
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~ ROGER POITRAS, CLERK CIRCUIT COURT ~`~~9 Y~y~16~~ ~
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~ Deputy~-~lerk
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' (To be exrcuteJ in Juplirale anJ ur~4mr1 fJeJ ~?•rth ('Irrk Circuit Courl, anJ Juplic~tr wuh Tax Assewx)
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