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Declar~tion of ~o~niciie and Citizens~hip
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'TO TIIC STATE AND COUNTY TAX ASSI:SSOR, ~~58 ,
ST. LUCIE _ CpUNTY, FLORIUA: F
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This is my drelaration of Uomicilc and Citizciuhip in thc Statc of Flo~ida that 1 am filing this day in
~ccordancc, and in conformity with Scction 222.17. Florida Statutes.
1 w3s formerly a lcgal rcsidcnt of ~1~~ , and I
r_ ~~r) stsee)
resided at ~ 3 3 ~ o~e ~~o~cr, i have changed my domicile to
(Sueet ~ad Number)
and am and I~ave bcen a bona fide residcnt ot the State of Florida since - day of
~ 9~~, and 1 residc at ~ ~ J~'1 u r e. r
? (suK~.~a N~me«)
~ ~ , . e . (:ounty, Florida,
(c`cr)
and this statement is to be taken as my declaratio~ of citizcnship, actual legal residence and domicile in the State
of Florida. -
{Insert hete snr pertinrnt fxts, such ss scle ot propertr or business. or relinquishment of employmenl at fotmer
domicile, removal ot famiir to oewr domicae, putchase of home, etc.)
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E~~TERI"?G CHILDREN IN SCNOOL: ~ HOMESTEAD EXEMPTION: [
If entering children in school, ~
please list their names:
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11~~~~~~~~~~~~~S~i~~y ~
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1 FURTHER CERTIFY that 1 will register at my local address when the registration books reopen, and
comply with all other requirements of a legal resident of this State. _
1 FURTNER CERTIFY hat t have no intention to return to my former domicile, and I intend to remain in
.
..~,,,,i::: ST. LUCIE , County,
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Florid~;~~it+t~ t}~`~~ cc~ir~ _
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Sworn to aind"sih`b'scribed before me this -.1 - day of ~ i~
.
_ A.Q. 19~~. ~ L T3" '3~
U8~ , Florida
ROGER .
g ' ~ Deputy Clerk
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