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Declaration of Domicile and Citizenship
. M
~
TO TH~ STATE AND COUNTY TAX ASSESSOR, ~
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ST. LUCIE _CpUNTY, FLORIUA:
_ 2841n8 ;
~
'I7~is is my drelaration of Domicilc and Citizenship in thc Statc of Florida that 1 am Giing this day in
accordance, artd in co~formity with Scction 222.17, Florida Statutes. ~
~ SOI~ ~ and I -
I was formerly a legal resident of ~u~-- f 7~R Pr ~-j
t (cilr) ' (staee)
resided at . However, 1 have changed my domicile to
(Street aod Number) •
and am and have been a bona Gde resident of the State of Florida since day of
' , 19~y and 1 reside at '3~~5 `s' ~e~ ~w ' ~
, (Strest sn umber)
~a~z~' Pi~rce , J~Z~• ~G~C/e _ County, Florida,
- (citr)
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State ~
of Florida.
(Insert here anr pertinent facts, such u sale of propertr or business, or telinquishment ot emploYment at fotmet
domicile. remoral ot family to new domicile, purchau uf home, etc.)
i
ENTERII~G CHILDREN IN SCHOOL: II. HOMESTEAD EX~MPTION: ~
If entering children in school,
please list their names:
_ ~ ~y A+~ e, ~.~:c~~
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57.1:uCtE ~~1Wt'Y ~ ~
- - ROCE~ PO?t~it~3
CLERK C;~atltd~~ ~
RECOR~ V`-Q~fifU"~~"'
I ~p ~ +r1 ~I'7'~
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1 FURTHER CERTIFY that I wiil register at my local address when the registration books reopen, and
~omply with aU other requirements of a legal resident of this State.
I FURTHER CERTIFY that 1 have no intention to return to my former domicile, and 1 intend to remain in
,~o r~ ~i erc ~ ST . LUC IE County,
~ ~
cc~~r)
Florida, permanently.
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~ Sworn ta aifd•s+:ib~~ before me this _ day of / e pJ
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J:i'~ l~ ~ ~ ~2Q~~ v r ~C U • / / R/ /~O~ ~ / a
~ . ' ' _ A.D. l 9~ ~I.Z~
~ ~ `r ~ i1TT co ~R ~rt P:~rce , Florida
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By ' <<, Deputy Clerk 3
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