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Deciaration of Domicile and Citizenship ;
3
•
TA THE STATE AND COUNTY TAX ASSESSOR, ~~~~08
ST. LUCIE CpUNTY, FLORlDA:
'R?is is my declaration of Domicile a~d Citizcnship in the State of Florida that ! am filing this day in
accordance, and in conformity wi~h Section 222.17, Florida Statutes.
1 was formerly a legal resident of ~ - and I
(Cl~r) ' (sisa)
resided at • . However, I have changed my domicile to
csas.t Nume..) ~
and am and ~ have been a bona ftde resident of the State of Florida since day of
~ , 19 and 1 reside at ~6
~
~L~~2-~." - -
($tt~t ~ad Numbec)
' , ~ . St . Lucie County, Florida,
(cur)
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State
of Florida.
(Insett Aere aor pertinent fsets, suc~ ~ ss~e ot ~r a~• « n~~~~"'s"~ ot em~orment <«~K
danic8e, removd of f~miy to new domicile. PurcAaae ot home. etc.)
. HOMESTEAD EXEMPTION:
ENTERING CHILDREN IN SCHOOL. J~
If entering children in school, PL-~
please list thei= names: .
; _ ,9~,~~,~ ~
~ ~..~~1.~~ ~
~~l ~ ~ ~ - -
- fILEO AMD RE~OWDEO
St. LUCIE COU TY FLA. ~
ROCER POITRAE
CLERK CIRCUIT COURT ~
RECORO VEP~FIED '
' $tr ID 1215 ?M'i~
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I FURTHER CERTIFY that I will register at my local address when the registration books reopen, and
comply with all other requirements oC a legal resident of this State.
I FURTHE CERTIFY that I have no intention to return to my former domicile, and I intend to remain in
' 8T. LUCIE County,
- •
Florida, pe~manently. cci~r) -
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. ~~y _ . ~ ~ SIGNATURE
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~ ~ v` bed before me this day of
~ Sw~~a~tec
~a~6gCn ` .
~''''~r;= s} ~ , A.D. 19 74 ~
~ , 8 r
~ ROGER POITRAS CIERK RCUIT COURT Florida
~ ~ ~.P_St-~ .
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gy ~ Deputy Clerk
~ ,
~ (To~ ~x~cebd ia duplkste ~ed oH~iasl C~ed with Clerk Citwit Co~ut, ~ad dupikate witA Tu A~o~)
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