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D~eclaration of Domic~te and Citizensh~p
• ~
TO THE STATE Ahp COUNTY TAX ASSCSSOR, ~SO~
ST. LUCIE CpUNTY, FLORlDA:
This is my dcclaration of Domicile and Citizenship in thc State of Florida that 1 am filing this day in
accordance, and in conformity with Section 222.17, Florida Statutes. ~
1 was formerly a legal resident of ~/a~ k /~o u n~/d;_Y~ , ~11Y ~0,~~ at?d I
=r-- (ct~r) (scste)
resided at .~.~~-t~.x °~sk - . Howevcr, I have changed my domicile to
(Streel aad Number)
and am and have bcen a bona Cde resident of the State of Florida since day of
9~ and I residc at - ' i
. (Stnet ~nd Number) .
- ~e ~~P ?'C P _ : ~ ~ P - County, Florida,
(c~tr) ~
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State
of Florida.
(insM Aere anr pertinent fscts. sueh ss s~le ot propertr or business. or relinquishment ot emplorment st formu
domic~e. removal of funily to aew domicile, purcAase o[ Aome. etc.)
ENTERING CHILDREN IN SCHOOL: ~ HOMESTEAD EXEMPTION: ~
If entering children in school,
please list their names;
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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 cequiremcnts of a legai resident of this State.
I FURTHER CERTIFY that I have no intention to return to my former domicile, and I intend to remain in
e r C F ST . LUC IE , County,
Florida, permanently. «i~r~
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3'w~}t~t. arid suf~f~~before me this ~ day of ~
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~ - A.D. 19_Z~ ~
- ROGLR
~ ~ , Florida
TT COllRT
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By puty Clerk
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