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~eclaration of Domicile ~nd Citiz~nshi~
"I'O TFI1: S1'ATL: AI~U COUN7'Y "1'AX ASS[:SSOR, 269112
St.Lucie
. COUN1'Y, F[.ORIDA:
• 4
Tliis is my dretar:~tion af Domicitc and Citixcnshi~i in ihc Statc of C'lorida that ! am Cling this day in ~
accordancc, and in confarmity with Scction 2?2.17, Florida Statut~s.
1 was fonncrly a legal resident of _.~~~-~1~~2~ :~C- ~ and !
~ ~~,~y' (s~s~e)
resideJ at r?~.'~ . Howevcr, I liave changed my domicile to
(Slreet anJ IYumberj
and am and have been a bona fide resident oC the State of Fiorida since day of .
TtOW ?
- ~~~~D-~, , 19.~~, and 1 /residc al f_~- ~-L _
~ r (Street and Numbet)
L~j~'t-~~~_~~~c/ , . St. Lucie County, I'lorida,
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and this st~tement is to be taken as my declaratiun of citizenship, actuai legal residence and domicile in the State
of Florida.
(Insert here any pertinent tacts, such u sale of property or business, or relinquishment of employment at fotmer
damit~c. rr: :~ra! ot ~ar~ely t^ ~•W ~^mir:le, nurchase of home, e~c.)
Entering children in school:~ Homestead Exemption: ~
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F+i~a ~NO R~ca~aED
ST. ~UCIE COUNIY F~A, ~
- CLERK
ClRCUI~ COIJRt ~
RECORD VERIFIED..~
~QY Z~ 8 49 ~ '~3
~.~rVJ111r"r
r FURTHER CERTIFY that I will registcr at my loral address when the registration books reopen, and -
compiy with all other requirements of a legai resident of this State.
I FURTHER CERTIFY that I have no intention to rcturn to my forn~er domicile, and I intend to rcmain in
_ ~
r ' St. Lucie County,
Florida, permanently. «''y~ _ ' ~
- ,
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Z
(Name)
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- . (
_ - ~ (Addreu) • z
Sworn tc~,and subscfibed bcforc me this day of ~
- ~ ~ ,c~'f,~.~~ E' A.I). 19 73 ~
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ROGfiR _ PO~~A~, CLERK CIRCUIT COURT .
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! = ~~'~s: -By- l~eput}?~~e d00t~21 FJi6E (lU0
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~IC . Q Q' t,(3'i~ be e~etulrJ in Juplira~r •rnJ un! in.il yd ~~Nh ~'I.vk Circuil C~~urt, ~ncl Jupli:~te with Tax Assrc~ur) j
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