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Dec~~~ation of Dornicite and CitiZensh:p
7'O 7'{1E S"TA'l'l: AN1) ('OUNTY '1'AX ASSt:SSUlt,
S~.Lucie
COUN"TY, FLOkIi)A:
Tl~is is tity dcclar:~tion af llomicilc and Citizcnship in thc Statc of florida that 1 am tiling this day in
acconlancc, and in confarmity witli Section 322.17, Florida S atutes. .
.
1~vas farnmrly a Irgal residcnt of L~`~ , and 1
~ (c~cr) (sa~~~
nsidcci at _ . However, I have changed my domicile to
(Strcel and Numbr )
and am and have bcen a bon~ fide reside~it of the State of Florida since - - day of
- now ~ .
19_~____, and I/residc at ~ ~ -
" (Street and Number)
, St. Lucie County, Florida,
(city)
and tliis statement is to be taken as my declaration of citizenship, act~~al legal residence and domicile in the State
of Florida.
(Insert he~t any pertinent facis, such u sate of property or businrss, or selinquishment of employment at formet
domicile~ trmoval ot famity to new domicile, purchax of hame, etc.) •
Entering children in school:~ Homestead Exemp~on: ~
_ ~
2s~~~a.
~ .
j
~ ~
~o e:_...,r.. ;
- ira ~ ~ a+~l"~'~~•,~v~a
-
_ _ :
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~ ' •
~
I FURTHER CERTIFY th:it I wiit register at my local address when the registration books reopen, and
compfy with ati other rcquir~ments of a lega! resident of this State.
i .
1 FURTHER CERTIFY that I have no intention to return to my former domicile, and 1 intend to remain in ;
: ~ .
~ St . Lucie Count
' ~._,c~~
Floridat.p~rmariently, . ' ~ y~ .
' •;'C,l. , ~ ` ~
~ - ~ ~
, - ^ ~
: ~i ' ; . . . (Name)
~ ~t. • • •~li~ . 3,~~~ • ~
F . ~ . ~.,~r ~ j + . : ~ - - Zi~, _
~ 'i : ~ ` (Addreu) .
. : = : '
~
.S~;o~n to~a~•~itps'ti.Yibcd before me this day of
;
9 , ` -
_ ~_~c.~~t.~-~-~ A.D. i9- 73
-
; ROGER POITRAS, CLERK CIRCUIT COURT
- -
3 . ~ - ~h l~_~ -
r 13y.--- - -
Deputy Clerk~ -
r
(To bt cxrcutcJ in Jn~~li, ~le au.i un~~in.~l filyd ~~~U~ l'IcrA ~~nJ Jupl~~~~~ Atkw.tj
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