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Dectaration of Dom~c~le and C~tizensh~p
~ ~ 2s~sse
TO THE STATE AND COUNTY TAX ASSESSOR,
ST. LUCIE CpU~y~ FLORIDA:
Tfiis is my dcclaration of Domicilc and Citizenship in the State of Florida that I am Rling this day in
accordan~, and in conformity with Section 222.17, Florida Statutes.
1 was fortnerly a legal resident of (rLy~.? U~~ St~-~~.`- o c~~~, D/~~~ ~ and I
(tytr) -
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resided at ~ . However, I have changed my domicile to
~ (Saeet .aA Nwne.~)
and am and have been a bona fide resident of the State of Florida since -Z ~ day of
_~L~'d , 19~~, and I reside at ~ ~ v` ~ ~ ~a .
~ ~ ( aad Nwabt)
~ ~ ~J~,~ . St . Lucie County, Florida, -
(Citr) ~
and this statement is to be taken as my declaration of citizenship, actual.legal residence and domicile in the State
of Florida: ~
(lasat Aae anr pertinent facu. sueh as sak o! ptopertr or business. ot relinquishment of qnpiorweat st torme~
domica.. remo~ral ot tamUr co aew danici~e. Durchsse ot Aom~. etc.)
REN IN SCHOOL: HOMESTEAD EXEMPTION: ~
ENTERING CHILD ~ .
If entering children in school,
please list their names:
S
~-1- 1v c f s~r~c G c- s
C` n!y /V i P_ S!r'i~l CrLr S .
- s~iu°c~£ ~owit°nr~~u~.
Roc~~ ~az~s
CI.E~tK C: ;Ciilt COURT
pFCOR~ YE~:~PiFO ~
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~ 294558
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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 of a legal resident of this State. '
I FURTHER CERTIFY that I have no intention to return to-tny former domicile, and I intend to remain in
o h~ ~ r l= h C~ ~ ST . LUCIE , County,
Fiorida, permanently.
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2 (;~17 _ Ep'G
~ IGNATURE
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S~iro taa~~~~~fore me this day of
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; , A.D. 19 ~
~OPl~'iTin 3 s
ROG,_I~. ~~'CLERK CIRCUIT COURT p,~,~,~~ , Florida
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gy t"'` Deputy Clerk
~ (To exetYled in duplicale snd wi~inal filed wilA Clerk Circuil Co~ut. ~nd duplicste with Tu A~essw)
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