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Declarat~on of Qomic~ie and C~tizen~h~p
1'U TfiE STATG A1~U GOUN7'Y' TA?i ASSL=SSOR, :
ST. LUCIE i__ CpUN'fY, FLORIDA: ~s
This is my drelaration of .Domicilc and Citi~cnship in the Statc ~f Florida that 1 am Cling this day in ~
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a~curdaiicc, and in conformity witii Scction 222.17, Florida Statutes.
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1 was formerly a Icgal resident.of _ and I ~
(Cyty! ~ (Slste)
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resided at • However, I have changed my domicile to ;
(Street snd Num ) _
and am and have been n bona Cde resident of the State of Ftnrida since day of
_ ~ , 19~~., and 1 reside at r,p Q~-5 U S, ~ S~ GL~ h
(SUeet •nd Numbe~)
F ~L~r~~ - - ~l/~ ~•~~S'v County, Florida,
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and this statement is to be taken as my declaration of citizenship, actual leg~l resiaence and domicile in the State
of Florida.
(Insett here any pertinrni tacls, sutb ss sale oi ptopertY a busioess, or relinquishment ot emplorment ~t tormer
domicHe. ~mowal of familr to aew domicile, purchase of 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 I will register at my local address when the reg~tration 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
~ ~ ~ L ~ ST. LUCIE , County,
Florida, permanently.
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~r,o;n ~o arid _~RbEd before me this ~day of ~
~ ' ~ A.D. l 9~4-. , ~
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~ , Florida ~
R_Q(;~ . ~ 7RCi17T C~L1~ ,
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B Deputy Clerk ~
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