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Declaration of Domicile and Ci~izenship ~
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TO Tt1E STATL• AnU C'UUNTY TAX ASSI:SSOR,
ST. LUCIE ~~UhTY, f=LORIDA:
71~is is my declaration of Domicile and Citi~enship in the Statc of Florida that l am filing this day in ~
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accordance, and in conformit~~ with Section 222.17, Florida Statutes.
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1 was formerly a legal resident of ~r " , and 1 -
~Ciir~~ (scste)
resided at -~~~(O . However, I have changed my domicile to
esa«. a.,t xumbe.) /
and am and ha~•e bcen a bona fide resident of the State of Fiorida since ` day of
19 7~- and 1 reside at ~ • ~ -
' (Street and Mu r)
~ . St. Lucie County, Florida,
ca~~) ~
and this statement is to be taken as my declaration of citizenship, actuai legal residence and domicile in the State
of Fiorida. .
e~ ,oy ~uMpi txa, ~ ~s s~te ot vro~~r o~ e~~ss• °r rclinquishment of employmeat at former
domiule. rea~wal ot famit~ to ner? domici~e. Purchase ot home. etc_) -
* • HOMESTEAD EX~MPTIOV: ~
ENTERING CHILDRE.~ It1 SCHOOL. ~
If entering children in school,
please list .their naraes:
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° FtLf 0 AND RECORQfo
~ S~ lt~lE C4U~TY fLA.
~ RO~Eti POiTRAt -
CIERR CtRCWT Cp11RT
E ~E~ YFRIFIED~~~
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~ Art li II s5 ~!'T~
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1 FLJRTNER CER7'IFY that I will regaster at my local address when the registration books reopen, and ;
~ comply with all other requuements of a legal resident of this State_ ;
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1 FURTHER CERTIFY that I ha~c no intention to return to my former domicile, and I intend to remain in ~
~ ST. LU~IE , County,
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Florida,,p~rA)anently.
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`^'3 't ~ • ' ' . _ . ~ / ~ ~i 1/.I
- . ~ . - / ---JS~.GtQwTURE
s~tibed beCore me this 1G ~ day of
~ SwAtt~~~i and ~
}t'•'~-~ A D 19 74 ~
x" - 1 g ress
RCGER POITRAS, CI ":tK CIRCUIT COUR'[' ~
_ _ _ ~L. -~c.cc~ Florida
~ g ~,~,,,~,1~ ~ Deputy Clcrk ;
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(To bt ~~c. . d~+plw~te anJ ~,~~~~~,i ra~-d ~.:th ('krA C+rauit Cuurt. rnd duplicrfc wilh Taa Asscswt) ~
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