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Declaration of Domicile and C~tizensh~p ~
. ;
TO THE STATE ANU COUNTY TAX ASSESSOR.
;
ST. LUCIC CpUNTY, FL.ORIDA: •
This is my dcclaration of vomicile and Citizcnship in thc State of Florida that 1 am i~ii~~g this day in
, ' ~ ' i
accordance, and in conformity~th Section 222.17, F1ar+d~_Statutes. " }
1 was formerly a legal resident of i~~ ~',~~~Y , G on~ and I
tCilr) (s~ate)
resided a ~ S` ~ ,~~n • . However, I have changed my: domicile to
~ " (S~tr t aad N mber)
and am and have been a bona fide resident of the State of Florlda siace day of
, 19 ~ ~ and I reside at ~o~ ~
. (suK~.oa N~~~)
' County, Florida,
~p~Z i ~ o ~il~. ~1.; . ~ ~
(Ci~r) , .
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State
of Florida.
~ (l~at here any patinent tacts. such as safe ot propertr or busiaas. or relinVuisAu~ent of emplormcnt ~t tormer
danicle. temoral of tamilr to new domicile. purchax of dome. etc.) .
ENTERYNG CHILDREN IN SC~i00L: ~ HOMESTEAD EXEMPTION: ~
If entering children in school~
please list their names:
~ ~ _ ~ _ ~..c~s '
Fi~Ea ~ECO~fo
~R~ ~ ST. LuCtE c~uNTr FLA. .
ROC~:~ =~tTR~S ~
~ C~ERK r.:fc~IT COURT '
REC~RO YE= F. D
~ac ~9 1 i3 PM'~~i
_ 2~954~
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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 C~RTIF"Y that I have.no intention t~ return to my former domicile, and I intend to remain in
- ST. LUCIE County,
,
Florida, permanently. (c~~r) -
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~~n t~~¢~~ s~ ,"hefore me this _1~ day of
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~ A.D. I 9~_ _
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~A' , Florida
ROGEK'" IRCLiTT C~~IRT_
By Deputy Clerk
• 440K ~:~7U PACt
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