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Deciaration o~ Dornicile and Citizenship t::;
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I~TY TAX ASSLSSOR, ~
TO TNL• STATE AND CUU
ST. LUCIE _CpUr1'fY, FLOR~DA: :
This is my dec{aration of Domicilc a~d Citizcnship in the Statc ot Fiorida that I am filing this day in
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accordancc, and in contormity with Section 222.17, Florida Statules.
~.fGa..r{s~ ~o _ , and 1
1 was formerly a Iegal resident of ~~~r~ _
~ ~ ~~dlQ 1~ . However, I ha~c changed my domicile to
:csidcd at . - S r-'
~su~e ~pa H~~en~ 3 ~ day of
and am and have bcen a bona fide res~dent of the State of Florida since
too$ s ~ ~ v-Q.,,,~.. ST .
~e C~. r , 19~.y and 1 reside at .~~KI iAA ~'IYAIOtf~
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a ~ ~ ~ 1.~,< < . o County, Florida,
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(c~~r)
and this statement is to be taken as my declaration ot cilizenship, actual legal residence and domicile in the State
of Florida. '
(Insert here snr pertinent facts, such u sale ot propertr o~ bminess. or relinquishmeal of emplolrmeot at tormet
domicile. ~emorsl ot tamilr to new domicile. purchsx of home. etc•) ;
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ENTERI":G CHILDREI`J IN SCNOOL: HOMESTEAD EXEMPTION:
If entering children in school, _
please list their names:
ST
~f~C1E COUMTQY~~,
ROCEA POITRA3 ~
CtERK CIRCUIt COIIRT
RECORO VfRIF1E0
S~ JO 1 ~9 P!I'l~l
I - 2~~~.16
1 FURTHEit CERTIFY that I will register at my local a edress when the registration books reoper., and
comply with all ott~er requirements of a legal res~dent of th~s Sta
I FURTHER CERTIFY that I have no intention to return to my former domicile, and I intend to remain in
ST. LUCIE , County,
~-~t ~ ~--t -
Florida, permanently.
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~ ~ before me this day of
Swo " ~d:~d s~ 04 ~ ~ ~~ti~~ ~ ~ •
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,s~'~~.: ~?T~, A.D. 19~~ -
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- • ; ~ Florida
; ~~n w r e -s
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gy ~ Deputy Clerk
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