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Declaration of Dor~nicile and Citizenship ;
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'1~0 ~'IiE STAI'E ANU CQUN1'Y TAX ASSL•SSOR, 289~13'7
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ST. LUCIE _ Cp~NTY, FLURIUA: ~
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'Il~is is nzy dcclaration of Domicile and Citizrr.ship in thc Statc of Florida that 1 a~n filir.g this day in :
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accordance, and in conformity with Scction 222.17, Flocida Statut~s. .
~ ~ S ; e ~ a~8 and 1 =
1 was tormerly a Ieg;~l resident•of ~~s ~Q ~
r t '~r) lst~te)
residcd at ~~p ru P~° n~ ~ r~-~~ . Howcver, I have changed my domicile to
(Stteet aed Number)
and am and have been a bona fide resident of the State of Florida since ~ s--~ day of
~ v?.` 19~1~, and i reside at _ 7s~ Z~a 10 1'~ a~ ~~r~° e- ~
' (Stccet s~d Numbe*)
a ~Ce c.~ ~ `~a~r~ - `T ~;,~~'~,E , ~ . L. ~ e County, Florida,
(ciir)
and this statement is to be taken as my declaration ot citizenship, actual legal residence and domicile in the State
of Florida. - .
(Inssrt here anr pertinent facts, such at sale of propettr or busineu, o~ reli~quishmrnt of empbrmept at tormer
domic~e. rcmo~al of familr to aevr domicile, purchsse of Aome, etc.)
ENTERING CHILDREN IN SCHOOL: NOMESTFAD EXEMPTION: ~
If entering children in school,
please list their names:
D Q 1?. 11 e h N~'~ ~ v~ ne y
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~~~ae~ Ke ~a h~~ a
~ Q e ~ ~ y
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1 ~ fILfD Rv~ R:G.ROED
2~ r 1~ e ~~c. d"It ~ K r~ e sT. ~va~ :~.:?IIY fLd.
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' Auc ts 9 32 ~N'7~ ~
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28~9~'7
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I FURTHER CERTIFY that 1 will register at my local address when the registration books reopen, and
comply witb all othsr requir~ments ef a legal residerit of this State. ~
I FURTi-iER CERTIFX that 1 have no intention to return to my former domicilz, and I intend to remain in ~
~ r ~ ~ ~ ~ ST . LUC IE County, '
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Florida, permanently.< .
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Sv~oiryf0:~nd's'~ths~fore me this ~ day of 1
. . . . ~So ~ f~~or~a'/' ~T~'PC ~ }
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- A.D. 19~4 ?
~ t rE ~ , Florida
ROGER P . . CLERK CIRCUIT~fiIIBT-
gy Deputy Clerk ;
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_ . ~ x ~31 ~~E 469 . ;
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