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eclaration af Dornicite and ~itiz~nsh~p ; ;
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TO TNE STATE A'~!D COUNTY TAX ASSESSOR.
_ ST. L~ICIE ~pV~Y, FLOKIDA: ~
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This is my declaration ot Domicile and Citizenship in thc Statc ot Florida that 1 am filing lhis day in ~ i
accordance, and in conCormity witt~ Section 222.17, Flosida Statutes.
L.9 L and 1
1 was formc~ly a Icg:~l resident of `~°S ~ • -
(Cl'tr) (S1ate)
-/~j,ei ~j
v~ . However, 1 ha~e changed my domicilc to
msidcd at
r (Sl~KI ~Id NnAOtt~
and am and have been a bona fede residcnt of the Stata of~~~~'Sl~'sinc~ ~ 2 ~day of
f~c~s i , 19~ and 1 reside at
(suKi.pa t~~me~.)
~ti i v~. County, Florida,
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and this statement is to bc taken as my declaration of citizenship, actual legal residence and domicite in the State
of Florida.
(l~~ 6s~e au7 pertiweat tacts, wcA as s~le ot Pr°pe~tf °r b~' ~~quuhment oi emploYment at formet
Boa~Kie. reo~oral ot fswilr to wr.r domicile. PurcAuc ot home. etc.)
*T II,UREPI IN SCNOOL: ~ HOMESTEAD EXEMPTION: ~ ~
E'.r1TERI..G CH
If entering children in school,
please list their names: -
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aL~l11~C1E G RECOR~o '
ROQER PpjTA~FIA.
~PFCOR~ ~Ek F~EO C'~~.
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1 FURTHER CERTIFY that 1 vsrill register at my local address when the registration books reopen, and
comply with aq other requir~ements of a legal resident of this Stase.
I FU~R.T~ ER CER'T[FY that I have no intention to return to my former domicile, and 1 intend to remain in
l" . . ~j~~l~ ST. LUCIE County,
Flap~
.:`p~~endy. - - cc-~r~
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gy~rnQ~a~d subscribed before me this ~ day of
~ - A.D. 19~.4.._. - ~ - ~
~c-,~~ , Florida :
:
ROGER POIT~AS _ _
By d DeFuty Clerk
- eo~~ ~?~1551 z
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