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Declaration of Domicile and Citizenship
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1'O TtiE STATL• AND COUNTY TAX ASSESSOR, . 2~43~b
ST. LUCIE CpUNTY, F1,ORIDA:
This is my dcclaration of Domicile and Citizenship in the State of Florida that ! am filing this day in
accordance, and in conformity with Section 222.17, Florida Statutes.
1 was formerly a legal resident of ~ t~ ~ ~~1a11~d.~~t , u'"'~- J~ and I
(~~r) (s~.~~)
resided at ~~n ~.1~ L~v~.~~ ~C' ~ a c~- . However, t have changed my domicite to
(Slreet snd Numbe~) '
,
and am and have been a bona fide resident of the State of Florida since day of "
~ ~
, 19~y and 1 reside at ~ 1 a~~ ~ u-- Ct'~'l~-
(St~eel and Number)
~ S~ _
(1~CY ~ , ~.t,c~.~- ~ County, Florida,
(~~y) .
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State
of Florida.
(Inutt Aae any pertinent tacts, such as sale of propertr or busincss, or ~elinquishment ot employmeot at former
domicile. removal ot family to new domicile, purchase ot home, etc.)
ENTERING CHTLDREN IN SCHOOL: ~ HOMESTEAD EXEMPTION: ~
If entering children in school,
please list their names: t;
4-
f!L.~O t~t. FEtQRDED
;1.- pLy~yC;._ G-~qMTir FLA.
FV~M:.1". rJiT~~a
~ +CIEFK .:~11T ~OURT ~
Fcrnp.-, y; ~
FE8 I I ID 38 ~N'1 ~
2'~438~ ;
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I FURTHER CERTIFY that 1 will register at my local address when the registration books reopen, and
comply with all other requirements of a legal resident of this State.
I FURTHER CERTIFY that I have no intention to return to my former domicile, and I intend to remain in
~ ' ST. LUCIE
~G't~ ,~t ~ ~ c~ , , County, :
Ftorida, permanently. Tcc~~y) ~
(F)
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Svyq~n•fb~a~n~ sub$critie~6~fore me this ~ day of „ ~
_ " ; '=t" ' i.~i z ' ~ J ~ < <11 Gti- r L
_ ^ , A.D. 19~___.. u ~
ROGET2~~ ~ B~ ~~i~v'L,~ S.-~ J~yt~ ~ c~. , Florida
By ~ Deputy Clerk .
(To be exrt d in duplicste and uriginai filed vrith Cletk Circuit Coutt, and duplicale with Tsx Assessot)
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