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268509 ~
Declaration of Domicite and Citizenship i
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TO THI: STATI: ANU COUNTY TAX ASSESSO[t, ~
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St . Luc ie COUNTY, FLORIDA: ~
'tl~is is my d~claration of llomirilc and Citizcnship in thc Statc of Florida ihat 1 am filing ihis day in
acconlancc, and in canfc~nnity with Section 222.17, Florid~ Statutes. ~ • ~
1 was formerly a legal resident of - ~~G~L~`nQ ,~v~di~v~ 1(~ and 1 '
(Ci1r) (St•te) f
resided at ~G~E~nv.~vc Re e-~ . However, I have changed my domecile to }
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and am and have been a bona Gde resident of tlie State ot Florida since day of
now ,
, 19 and 1/~eside at 32~ a S`~ j-O~ I Q~ ~
(Street and Numbe~) !
Q~~Qe~ • • St. Lucie County, Florida,
(c~~y) ~ -
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State
of Florida.
(Insert here any perlinent facts, such u sale of property or business, or relinquishmenl ot emploqment st formet
domicile, remo~al of family to new domicile. purchau of home. etc.) ~
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Entering children in school: ~ ~ Homestead Exemption: ~
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- ST.
LUCIE COUMTr FLA.
. RQCER FO~TRAS ~
CI.ERK C~RCtliT COtJBT
RFCOR~ YER!FIED.~,~,~~. -
No~? IS I 22 PM'73
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I FURTHER CERTIFY that t will register at my local address when the registration books reopen, and
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comply with all otlier requirements oi a legal resideni of this State.
I FURTHER CERTIFY that I havc no intention to rcturn to my former domicile, and 1 intend to remain in
. p ~~e Q~C'~' St . Lucie , CountY,
Florida, permanentiy. cc''r~
~ 'K\Q.S. ~FFnp~ ~E
(Name)
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` S~vorn to and subscrib~•d bcfor~ mc this day of .''~~ir`
i ~ - _ ~'t.'• ~.s ' ,k,'•*'.., 'lLt4'.~ii-
~ A.D. 19--73 • _ = j~-~~.~
c~ ~i ; "s: ;
~ ROGER POITRAS CLERK CIRCUIT COURT =
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. . _ . . _ . . . _ .~..~~C.e~ Cn ~ %n t? . ~
_~y_- _ uty Clerk--- `--'..'~'~.>`•',f'
(Tu be.~rcuteJ in Jupli:ale anJ uiiy~mrl f~lcd with ('Irrk Circuit Court, anJ Juplicatr rrith 7aa Assesso~) ~
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