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Dectaration of Domicite and Citizenship
UNTY TAX ASSESSOR, ~~~2
TO TNE STATE AND CO
ST. LUCIE ~pV~y, F~ORIDA:
This is my declaration of Domicile and Citizenship in the State of Florida that [ am flling this day in
accordance, and in conformity with Section~222.17, Florida Statutes. '
1 was fonnerly a legal resident of ' • d I
ta )
. However, 1 have changed my domicik to
resided at
(Stnst ~d NumbK)
and am and have been a bona fide resident ~ of the State of Florida sina day of -
, 19~~, and I reside at Q Sd•
(StrNt sed N~a~bK)
F~ ~1e Q~ St . Lucie County, Florida,
. •
ta~r)
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State
of Florida.
~~e..r~ een apr v~~+Mne taca. suca as s.k ot proo«tr o~ ~nas. a. ramqui~umsn~ ot.aoaorm.ac t«m~
domici~e. temoval ot faa~ilr to asw domieile. Purchase ot home. etc.) ~
ENTERING CHILDREN IN SCHOOL: ~ HOMESTEAD EXEMPTION:
If entering children in school, -
please Iist their names:
A RfCOitD YfC111~~"ffOT.~ ~
!'~~V~Q L~t ~QRd1hNC ~R
T ~ ~l 9 ez AM'l~1
_ 2923~2
~ ~ I~ d r~ ~ Ge »~~N+~ a~- PP~G. ~i 6~R Gl..~s
(R~;~~h9 a e f'''~ y '
~ • ~ 0.~lh~ ~1 I.~C R s
` ~Laht WoRk~ • ~ .
~ ~ R ~a~f`~. P~~a«, ~C~. t~~ G.I.
TRa ~ y ~ -
a.cc . -
1 FURTHER CERTIFY that I will register at my local address when the reg"~stration books reopen, and
comply with all other requirements of a legal resident of this State.
I FURTHER CERTiFY that 1 have no intention to return to my former domicile, and I intend to remain in
R e t ST . I.UC IE County,
,
Florida, permanently. cc~*r) .
.
~ . , .
~ - • ~ • - ~ ~
. ~ ~ GNA
.
~ ~ : . . ~
4 Sworli:to d subscrJ~ed.~efore me this day of
' A.D. 19 74 - . •
, ~
ROGEIt POI'~ftAS CLERK iRCUIT COURT ~~~i, Fiorida
~ gy Deputy Clerk
(To M• ut~d i~ daplicst~ aad o~itins~ filed with Ckrt Cireuit Co~t. ~nd duplkate with Tu Aa~ea~or) •
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