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Dec~aration ~f Domicite and Citizenship
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1'O TIIL' STATE AhU C'OUNTY TAX ASSl:SSOR, ",~16~
ST. LUCIE COUNTY, I~LORIDA:
This is my dcclaration ot Domicilc and Citi~cnship in the Statc of Florida that 1 am filing this day in
acrordaiicc, and in conforniity with S~:ction 222.! 7, Florida Statutcs.
I was foRnerly a Irgal resident of AQ O~Q , ~NH eSSe~ and 1 ~
(c~~r ~su~r~ ~
r~sided at _~_1~-~ e -S{ . However, I have changed my domicilc to ;
esuK~ ~oa H~a~ee~~ :
and am and have been a bona fide resident of the State ot Florida since l'~r day of '
~ r,
JV'D J ) ~ ~ .
j~~u n~- - . 19-.~, and 1 r~~sidc at -
i (Street sad Number)
_ o~ t j~ ~~G ~o St . Luc ie County, Florida,
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and this statement is to bc taken as my declaration of citizenship, actual le~al residen~e and domicile in the State ~
of Florida. - ~
(lasert here snY pert:eent fxls, such as sak of properlr or busin~s. or ~elinquishmmt of emplorme~t at tormet ~
d~micile. rcmo~al of family to new domiciSe, purchase oi home, etc.) ~
. HOMESTEAD EXEMPTION: ~
ENTERIhG CHILDREN IN SCHOOL. ~
If entering children in school,
please list their nsmes;
e~olra. Li c%C,
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~~;6~s-f" ~r•~e~ce ~~tee~,~
/~/I~ e ~ e t ,
, _ ~ ~t u.e ~y ~wa ~c~~ ~'a
c iT. ~YCiE COtl11~Y FtA, i
ItOCER POIT~AS I?
. CLER1~ C!R~tllt COt~T
1tfCOR~1 YERIFIED
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j . A~a 2l i0 u AH'1a
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1 FURTHEP. CERTIFY that 1 wili register at my local address when the registration books reopen, and
comply with aU other requirements of a tegal resident of this State.
I FURTHER CERTIFY that 1 have no intention to return to my fc•rr:?er domicile, and I intend to remain in i
_~or t PL°YG ~ ST. LUCIE County,
tcnr) '
Fiorida, permanently.
' a;u.l~~
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S.
< . - _ S IGNA'1'URE
-
_ . _
r, T~,"~fsciib~d ore me this ~ day of
Swerti to aad;s~,t ~ -
. - ..~Y. A.D. 19 74 3 S / U .S'- .S
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~pG~~ ~RK IRCUIT COURT ~~m f- , Florida
^ •~~.~tfNll~i` ~ ? , •
_ { w ~~l~'t `,1~ ` .
g ` ~ Deputy Clerk .
y
" (jp be a ated io duplicale and ori~i~ il filed wilh Clerk Cit~uit Coutt, snd duplicate with Tax Assessot)
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