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Deciaration of D~rnicii~ and Citizenship ?
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TU THG STATE ANU COUNTY TAX ASSI:SSOR. ~BS~+ i~ ~
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ST. LUCIE __~pUNTY, FLORIDA: ~
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'i'his is my dreiaralion of Domicitc and Citizcnship in thc Statc of Florida that 1 am filing ihis day in
accordancc, and in conl'orniity with Scction 222.17, Florida Statutes.
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1 was formerly a icgal residcnt ot' ~.q~-:
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. However, I have changed my domicilc ta
r~sidcd at _ b,,
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and am and have becn a bona fidc resid~nt of the State of Florida since day of
~t-~j~' ,~L~ , 19_.i!~ and 1 residc at ~ s~~ U C.C~/' G _
(Sueet zad iVurnber)
~T S~! Ue S j`- ~ UC`;%~~ County, Florida,
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an~ this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State
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of F=lorida.
(Inserl Aere aay petlinenl fxts, such as sale ot properlY a b~~• a telinquishment of employment at tormet
domicile, remov:l o( fimiir to new domicile, purchase of home, ete.)
? HILDREN IN SCHOOL: II. ~ NOMES'[`EAD EXEMPTION: ~
E.~TERI_ G C ~
If entering children in school,
please list their names:
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1 FURTHER CERTtFY 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 that t have no entention to return to my former domicile, and I intend to remain in
~~J-- ~ UC~~_r _ ST. LUCIE , County,
Florida, permanently.
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Swqln to and'~Hseribed befcre me this day of ~ v~
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ROGE pug~ S~ U~/~~ , Florida ~
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gy C~or.l~~Deputy Clerk
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