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Dectaration of Dornicile and Citizenship -
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"10 "fllli STATG ANU ('OUNTY TAX ASSLSSOR, ~s'~S
ST. LUCIE t
_ COUNTY, CLOlt1UA: ~
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Tl~is is my dcclaration af
Uomicilc and Citizcnship in ihc Statc of Florida that 1 am filing this day in
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a~cordance, and in conformity with Section 222.17, Florida Statutes. ~
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1 was fotmcrly a Icgal residcnt of (State)
(ci~Y) e;
rrsided at ~ ~-T . However, 1 have changed my domicite to ~
(Sttcet and Number) ' ~ }
and am and havc b~~cn a bona fide resident of the State of Florida since ~ T~ day of i
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~ r~_.s.. ~r Al//E
~"~T , 19_~, and 1 reside at -~-~~r.~~ • ~
(Street and Numbet) ~
St . Lucie County, Florida, ' t
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~nd this statement is to be taken as my deciaration of citizenstiip, actual le~al residence and domicile in the State
uf Florida. `
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(Insert here any pe~tintnt fscts, such u sale of property or busirtess, or relinquisAment of employmrnt at tormer
domicile. rcmoral oi family to new domicile, purchase uf home, etc.) ~
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Er1TERiNG CHiLDREN iN SCHOOL: ~ HOMESTEAD EXEMPTiON: i
If entering children in school, ~
please list their names: .
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1 FURTHER CERTIFY that I will register at my local address when the registration books reopen, and
comply with all other requirements of a legal resident of this State. F
I FURTHER CERTIFY that I have no intention to return to my former domicile, and I intend to remain in
~ ~ ~ ~2 ~ ST . LUCIE County,
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Florida, permanently.
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~ ' ~~.J ~ S IGNATU
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~ Sworn .to Sttd. 3ti~~t,b~~~ore me this ~ day of . _
~ ' , = ~ ` ~j A.D. 19 74
~ _ ;;~N. _ ng re s s ~
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RpCI;;T~;". ~.R~ • ~tK IRCUIT COURT , Florida ~
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~ n ~ ~ ~ Deput Clerk ~
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licate and ori inal t~ird with Clerk Circuit Court, and duplic~te vrith Tax Assesso~) ~
~ (To be exe ted in dup B ~
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- aoox2~30 ~~1603
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