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Deci~ration of Da~nicite and Citizen~hip I
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TO THE STATE ANU COUNTY TAX ASSL'SSOR, ;
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ST. LUCIE ~Y~UNTY. FL(aRIDA:
This is my dccla~ation of Domicilc and Citizenship in thc Statc of rlorida that 1 am Cling this day in
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accorJance, and in conformity witli Section 222.17. Florida Statutcs.
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1 was formerly a lcgal resid~nt of •
~ (Cilr) (s .te)
n P~ . However, 1 have changed my domicile to
r~ sidcd :~t ~ S d f : k, :
/ s ~ ~l
(Street snd Num~ec)
day of
and am and have bcen a bona fide resident of the State of Florida since
.~u.~. , 19_ ~ ` and I residc at ~ ln/ /~iy ,L G A v~ _ >
(St~et ~nd Number)
. s ~L ~ < i , ; e County, Florida, .
c~ -v
- ~ (City)
and this statement is to be taken as my declaration uf citizenship, actual legal residence and domicile in the State
of Florida.
(Ioserl bere any pertinent facts, such u sale of property or busincss. or telinquishment of employment at tormer
domicile, ~emo•al ut tamilr to ~ew domicile, pwcAase of home, etc.)
, ~ tiOMESTEAD EXEMPTION: ~ ~
E.ITERI..G CHILDRE.j IN SCNOOL:
If entering children in school,
please list their names:
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,r, - e r ~
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/~/I/.ti e ~7 e !1 /,r~ ~ t,~`
/ " f~' Lf 0 AfID .
T~/ e f P~ R rl 4%' ~~S't s~ ~~'E ~6
C~ERt CIRGNT i~t ~ ~
RECORD YER~flEp...,,~,~
~C 1~ !I 0~ M!'l~
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I FURTHER CERTIFY that I will register at my local address when the registration books reopere, and
cor:iply with atl other requirements ef a legal resident of this State.
1 FURTHER CERTIFY that I have no intention to return to my former domicile, and I intend to remain in
ST . LUCIE , County,
Florida, permanentiy.
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• .I f ` day of ;
Sworn.ta.~nd subscr,r"~'d, hefore me this ~
r . ~ _ A.D. 19~.~.. ~ ~
~ ; a , Florida ;
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t Deputy Clerk ~
By "''f °
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~ooK 231 976 ~
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