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D~cturu~.i€~n of ~on~E~Eie ~~d ~~~iz~;~sh:~~ ,
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'I O 7'!t~ S7'ATG AND CUUNTY TAX ASSI;SSOtt, ~
st . Luc ie courv-rv, r• ~oR~nn: ; 2~01`~9
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Tliis is my dcclaration of Domicit~ anci C'itixcnsliip in tl~c Statc of Florida tliat 1 am filing this day in
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arcordancc, and in confarmity with Scclio» 222.17, Flori a St utcs. • . ~
1 was formcr! a Ic al rrsidcnt of , nd i
Y €
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resided at ~-s . Howcver, I havc changed my domicile to .
(Slteet aed Number) ~ +
and am and have been a bona fide residcnt -of the State of Florid since ~ day of
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192.Z., and I /Fcside ai ~ ' .
' (Stteet snd umbet) ' ~
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^ ~ ~~2~,~ . St. Lucie County, Florida,
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and tliis statement is to be taken as my declaration of citizenshi~, actual legal residence and domicile in the State
of Florida. ~ -
(Inseri here any perlinent facts, such u sale oi pro{+erty or busineu, or reli~Quishment of employment at for er
domic~7e. temovsl of fsmily to new domicJe. purchase ot~~ e,
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Entering children in school;~ Homestead Exemption: ~
- S~ttlClE GOUN~MA,
_ ROCER '01)RAS
. CLERK ClRCUIT CQURt 4
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~ - Doc 10 I i u9 AH'~3
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~ - ~01'79
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s I FURTHER CERTIFY that I~vill register at my local address when the registration books reopen, and
~ comply with all ot~zer requirements of a legal resident of this State.
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~ I FURTHE IFY that 1 have no intention to return to my former domicile, and I intend to remain in
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§ ~r St . Lucie , County, ' ~
~ ~ ~lorida, permanently. ~ ~ ~ '
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t . . ~ ~ c9tiLyL
(Name)
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Sworn~f~ ~1d sub~sct~it~cd bctor.~ me tliis ~f v. day of
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jt~ p.D. 14 73
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p : J . : ~ f . ' ~ . . .
~ : RO~~ ~POI,T$~S _ LERK CIRCUIT. COURT ~ ~ ~ ~
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. - ~y- De ~ty ).erk
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(Tu tre ezecul in dupGca~r and oripi~~.~l IJ.•J wilh ('I; ~A Ci~cuit ('uurl. auJ d~y~Gcale ~vith '!at A~u•s+ur)
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