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Deciaration of Domicile and Citizenship
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TO THE STATE AND COUNTY TAX ASSESSOR, ~51+7 :
ST. LUCIE COUNTY, ~LORiDA: I
This is my dcclaration of Domicilc and Citizenship in ihe Statc of Florida that 1 am filing this day in'
accordance, and in conformity wjth Scction 222.1~, Florida Statutes.
I was formerly a legal resident of~lL.!~~ p~'~~ ~-p~~ ~ ~~l' C~ ~d I
Citr) (Staee)
a? . However, I have changed my domicile to ~
resided at •
(Strest ~nd Numbet) ~
and am and have been a bona Rde resident of thc State of .Florida since ~ day of
~t GltST _ , 19_L~._, and 1 reside at
. (Street snd Number) ~
~0 2T • ~ ~c e ~ ~ ; . L ~ County, Florida, ~
(Ct~r) ; ;
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 taets, such as ssle oi propertY or business. or relinquishment ot employment at foro+et
domic~e. remoral of family to new domicile, purcdsse of 6ome. ete.) •
ENTERING CHILDREN IN SCHOOL: HOMESTEAD EXEMPTION: a
If entering children in school,
please list their names:
/~1~ ~i A ~o~ _ Cl ME~LA7C
fILEO ANU RECORDED
S?.lUC1E CiIUNtY fl~.
RIiCER r~1TRA5 ~
CLERK CIRGWT COURT ~
RECOR~ ~~~~F~~~
Auc 19 11 t2 AN'Z~1
i - - ~95~'7 ~
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I 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. .
I FURTHER CERTIFY that I have no intention to return to my former domicile, and I intend to remain in
~n ~T. ~ , ~u ~ ~ ~ _ ST . LUCIE , County,
~ (c~~r)
Florida, permanently.
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•~S',w~ ;!o'a+~c~ ~ scribed betore me this day of ~
^J .~Ico„- A.D. 19~~ .
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~ ~c.~ Florida
R~R, B(3~S_,~ CLE 2T- '
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- ~ ` Deputy Clerk
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