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Declaration of ~ Domicile and Citizenship
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TO THE STATE AND COUNTY TAX ASSESSOR,
ST. LUCIE CpUNTY, FLORIDA:
This is my declaration of Domicilc and Citizenship in the Statc of Ftorida that 1 am filing this day in
accordance, and in conformity with Section 2~2.17, Florida Statutcs.
1 was formerly a tegal resident uf ~'''-~''~lO~='''~ , and I
(C+tr) (sua)
resided at . However, I have changed my domicile to
( t aad Number)
and am and have been a bona Gde resident of the State of Florida since 11 day of
, 19...~~., and I reside at
~ ~ , ~ ( aad Nuwber)
' _ St . Luc e County, Florida,
(cter)
and thi~ statement is to be taken as my deciaration of citizenship, actual legal residence and domicile in the State
of Florida. -
(Inserl here anr pertineot facts. such u sale of prope+ty o~ busiaas. or ~e~~u9u~shmsnt of employment at former
domicile. remoral ot familr to new domicile, purchue of home, ete.)
. HOMESTEAD EXEMPTION:
ENTERING CHILDREN IN SCHOOL. .
If entering children in school,
please list their names:
FIlEO AMu AEC~ROf~
iT.tuciE cou~ r f
ROSER i01TA~S `
CIERK CfRCU1T COURT
RfCnpD vE~~FtEo
O~t i l 2 0o f M'7~i
; 293355
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I FURTHER CERTIFY that I will register at my local address when the registration books reopen, and
compiy 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
ST. LUCIE County,
,
Fiorida, permanently. . tci~r~
.
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Sw~~~pd.s
~_r~b¢q~~ before me this ~ day of
! ' - ~a",
, , ~ C • 74
~ c.,, ~ _ ; A.D. 19
i ng re s
ROGER POITRAS C K CIRCUIT COURT , Florida
- gy Deputy Clerk
(To b2' ecuted in duplicale and oriRinal t'tled with (.'ferk Circuit Coutl. ~nd duplicate wilh Tan Assesao~)
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