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Deciaration of Domicile and Citizenship
TO THE STATE AND COUNTY TAX ASSESSOR, '2~~~9~ ~
ST. LUCIE CpU~y, FLORIDA: ~
'I1~is is my declaration of Domicite and Citizenship in the State of Florida that I am filing this day in
accordance, and in conformity with Section 222.17, Florida Statutes.
I was fotmerly a legal resident of . '2~ and I
_ (c:~cr) (saa)
resided at 'u'^~ . However, I have changed my dojnicile to
' (Sttee Numb~r)
and ain and have been a bona fide resident of the State of Florida since ~8 ' day of
, 19~., and I reside at - - " " ~ ~ .
- tsa+.~.na Wwae.r)
_ St. Lucie County, Florida,
(cier)
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State
of Florida.
(Insert Aere aar pettinent tacts. such as sdt ot pwpertr ot business. or rai~u9uahmeat ot ea~plormeat at tora~et
dwnie7e. removsl of tamilr [o oew domicit~. Purcbsse of Aome. etc.)
. HOME STEAD EXEMPT ION : ~ _
ENTERING CHILDREN IN SCHOOL.
If entering children in school, 4=--~
please list their names:
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I FURTHER CERTIFY that 1 wiU register at my local address when the registration books reopen, and
comply with aU other requirements of a legal resident of this State.
I FURTHER ERTIFY that I have no intention to return to my former domicile, and I intend to remain in
• ST. LUCIE County,
,
Fiorida, permanently. «i"'~
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~ , • • - _ . S IGNATURE :
~ Swocn tb and'subsc~tib~(~before e this °2~ day of
~ ~ 74 / .,s" ~ ~ .
~ ~ A.D. 19 r
~u.u,~ , Florida
ROGER POITRAS CIERK CIRCUIT COURT
~
~~1-~-~Deputy Clerk
By
(TO ~~=~cdNd ia dupikste snd orisinal fikd with Cktk Circuit Cortt. aad duplic~ts aith Tss Awaror)
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AGO F'rrm '1
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