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Declaration of Domicile and Citizenship
'PO THE STATE AN D COUNTY TAX ASSESSOR, . ~~s+ ~
ST. LUCIB ~pV~y~ FLpRIDA: ~
"'Rtia is my ~declaration of Domicile and Citizenship' in the State of Florida that I am t3ling th4 day in
aooord~nce, and i~ oonfornuty with Sectio~ 222.17, Florida Statutes.
Eastham ~~s • a~d I
I waa fo~ly a legal res~dent of •
r~.sided at ~an Itoad . However, I have changed my domlcik to
~ ~..a Hwae..~ ~
and am and have ban a bona fide nsident of the State of Florida sinoe lOth day of
' I.ot . 512 ~to 1 i~day Ont at St . Lu~ ie d'
October , 19 and I reside at ~
(sen~t aoe tiwseK) _
' St . Lucie ' Cu~rity, Ftorida;
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and this statement is to be taken as my declaration of citizenship, actusl leg,al residencx and domicilE in the State
of Florida.
(l~ert Awe snr Partiaeot taets, snd~ as saN ot prope~tr a Dmiaas~ or *~Iia4ui~Ameat ot ~aapbra~at st tacau .
aow~ea.. ce.o.a~ ot t.mur a ne.r dom~ew. P~t~aM-of Mo~~. eteJ .
. ~ - ~ IiOI~STEAD EXEMPTION: ~
ENTERING CHILDREN IN SCHOOL. ,
If entering children in school, ~
please list their nemes: - -
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. Qf.ERK C1RC1lIY CO{lltT -
~ - 1tE40R0 VER~fi~p -
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1 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 my former domicile, and I intend to remain in
_ ST. LUCIE Count3r, _
Florida, permanently. ccHr) /e~? " C - ~~t!/irVg -
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- ,.''gty.lt;4 C : s • - $1 TURE
~a~;~.:~..: f~:~~ ~~ISY
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`~~_v4~aRn~~-aq~ ~a~~~d before me this - day of
_ .~s`~~;~: ;:•r; °e= 74 0 -
-~r~~~- ~ ~~O- l~oX i 3
, • ; ~ A.D. 19 -
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~'•-,~{g~ ~RAS CLERK CIRCUIT COURT ~i Florida
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gy Deputy Clerk „ . , -
('Y'o b~ ted b~ duplieate wd oripnsl tAed vrith Ckrk Clnwit Court, asd dupHcst~ witA Tat Asu~)
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