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Declaration of Domicite and Citizenship
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TO THE STATE AND COUNTY TAX ASSESSOR, `
ST. LUCIE Y ~SQ~3 . ~
~ COUNT , FLORlDA:
'Il~is is my declaration of Domicile and Citizenship in the State of Florida that 1 am filing this day in
accordance, and in conformity with Section 222.17, Florida Statutes. .
1 was foRnerly a legal resident of Y~ s c a~ a v , j~/ t~ ~ t S-~ / and I
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ded at ~ s~ f~~ ~ N~~ . However, I have changed my domicile to
and am and have been a bona fide resedent of the State of Florida since S~ h day of
~'1m~ , 19~ and I reside at f ~e s r_ /v .ti ~ l/ ~l -
, su«c aed rumeer)
~ r 7f" -~~~P~ r ' , 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. ~
(tasert Ae~e sar pertineet tacts, such at aale ot pwpertr or businas. or relinquithment o[ emplormeat at [otma
doa~ic~e. rtmoval ot [uailr to aew domkde. purcUase ot Aome. eic.)
ENTERING CHILDREN IN SCH40L: HOI~STEAD EXEMPTION: ~
If entering children in school, ~
please list their names:
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ay,L'~'l o n~ /?loYCroSS,_Ur,
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I FURTHER CERTIFY that I wilt register at my local address when the registration bool:s 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
F o r t ~i.e r c P ~ ST. LUCIE , County, ~
Fiorida, permanently. cci'r~
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t;~"'• ~ 'r=- ' ~ SIGNATURE
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S~ir,o r~, j~b G.~ ~ fore me this da of
i~au~a ~ y
_ r 1>' ~ ° _ 74
.t` - A.D. 19 0 o s e~ v~/
` ~ 'vs;st - - "'P i ng a'dr~'~'~
_ R(~o ` '~`?~CLERK CIRCUIT COURT ~or~" ~i c C ~ Flotid8
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~ gy , puty Clerk ~~1.1~
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(To ~ ex ted in duplicate and orisinsi filed with Cterk Circuil Court, and duplicste wilA Tsx Aa~aor)
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