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Declar~tian of ~ornicQl~: ~nd Gstiz~~:~hi~ ~
7'U THIi STAT[: ANU CUUN7'Y ~rna Assi~.ssoii, 2'71800 ~
St.Lucie , CUUNTY, 1~L,ORIUA:
Tius is my drelaratic~n of l~amicilc and Citizcnshi{~ in thc Slatc of l~lorida that 1 am filing this d:ry i~i
accotdancc> and in conformity wii~i S~rtion 22.17, Flori~la Statutcs.
1 was Cormcrly a Icgal csident of _ and I ;
' . ( ' Y ~Stale) i
resided at ~ vcr, I h.~vc changcd domicilc to
(Str nd Number) !
and am a~td have bren a na fide resident of tl~e St e of Florida since ~ - day of ;
YlOW ? ~ ?
, 19_ and I/~residc at s] `
( t and Numbet)
~ ~ , St . Lucie County, Florida,
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- and this statement is to be taken as my declaration of citizenship, actiial legal residence and domicile in the State
of Florida.
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(ins~ert here a~y perlinent facts, such u sale ot property or business, or relinquichment ot rmptoyment at former ~
domicile, removal of family to new domicile, purchase of home, rteJ ~ ~
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Entering children in school:~ Homestead Exemption: L1-1 ~
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iT. ~l{CIE COUMTY ft~.
R06E~? POiTAAS
~ CtERK'C•~.L!?j' ~OtlRT
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I FURTHER CERTIFY that I rvil! registcr at my local address when the registration books reopen, and
; comply with a!1 othcr requirements of a 1eDa1 resident of this State. ;
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I URT E RTIfY that 1 i~av na intcntion to return to my forn~cr domicile, and 1 intend to rcmain in ;
` ~ ~ ,~,~Q/._ St. Lucie ~
~ County,
Flonda, permanently. ~ ~ ~ ~ !
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