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Decfarat~on ~f Dom~c~le and C~tiz~nsh~~
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"1'O T1iE STA TI: AND COUNTY TAX ASSESSOR,
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_ ST. ;
UCIC rnUNTY, rLORIUA: ~
This is my drelaratiun of Do~r.icile and Citir.enship in the State of Fiorida that I am fil~ng this day in
acconfancc, and in conformity witli Scction 222.17, Florida Stat tes. ~
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I was formerly a iegal nsident of ~ , and I
tCitr) ~ (Staee?
resided at ~ - . However, I have changed my domicile to
(Street and Number)
and am and have been a bona fide resident of the State of Florida since _ ~ day of
, 19_„~. and I rsside at ~
~ (Stteet and umbe~)
_~~~~~.~r.Piu~ , P County. Fiorida,
(~~r1
anci this statsment is to bc taken as my declaration of citizenship, actual legal residence and domicile in the State
of Florida.
(Iwseri here anr petlinent facts. such u sale ot propertr or businas. or relinquisAment ot emploYment at tormer
doatic~e. removal ot f~milr to new domicile. purch of Aoms. etc.)
ENTERING CHILDREN IN SCHOOL: HOMESTEAD EXEMPTION: a
If entering children in school,
please 1' t their names:.. -
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fILEL' ± ~'_G~ROED
ST LU~:: :~.;HT'c FlA_ ~t~
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A~ [Z 4 is PH'~~I
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I FURTHER CERTIFY that I wil! register at my local address when the registration books reopen, and
:.omply v?~ith all other requirements of a legal resic~Pnt oi this State.
I FURTHER CERTIFY that I have no intention to return to my former domicile, and I intend to remain in
~dd ~ p~~ ~ P ~ ST. LUCIE , County,
(c;~r)
Florida~ mane~tly.
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Swoinff~d s~t~~~d before me this ~-~day of ~ + ~ e~-nh
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-C A.D. 19~~t~ '
ROGER P ~~T , Florida
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By~ Deputy Clerk ~
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