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Deciaration of Domicile and Citizenship
'TO TN[: STATE ANU COUNTY TAX ASSESSOR,
_ ST. LUCIE _ COUN'fY, FLORIUA: ~3
71~is is my declaration oi' Domicile and Citixenship in the State of Florida that I am filing ihis day in
accordance. and in conformity with Section 222.17, Florida Statutes. ~ _
~ and I
1 was formerly a Icgal resident of ~t~ .~~Q~~~ u<<~
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/y3 ~7~~ ~:~-u~`P . However, I have changed my domicile to .
residcd at
(Street and Number)
and am and have been a bona fide resident of the State of Florida since day of
, 19~ and 1 reside at --~~5 ~
(si ~.~a N~~e~)
~.71, c u.r ~ , ~c-c c.c~ County, Florida,
(cier) - ~
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State
of Florida.
(insert here any pertinent fsets, such as ssk of propertr or busine:s. or relinquahment ot emplorment_at forma
domicde. remoral of tsmily to new domicile, purcha:e of home. ete.)
ENTERING CHILDREN IN SCHOOL: HOMESTEAD EXEMPTION:
If entering children in school,
please list their names:
!'Q~C~6 i~ /ORC.UT~~r--
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NR tS Ti~r/~ ~ R~ ~ ~11 T/L~
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CL~Rl~ ~:~~~tUT C4URT
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I FURTHER CERTIFY that I will register at my local address when the registration books reopen, and
comply with aU other requirements of a legal resident of this State.
I FURTHER ERTIFY that I have no intention to ret~irn to my former domicile, and I intend to remain in
_y ST . LUCIE , County,
Florida, permanently. ~~'t''~
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- ~-$~tr to and s'~cnbed before me this ~ day of d S ~ /1~ -
°'d~. - ~ a~
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' c ~ ' • A.D. 19 74 _
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- ~ iG~ Florida
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_ By Deputy Clerk
. 6001~~+JV PACE4V~
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