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Deciaration of Domicile and Citizenship ,
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TO THE STATE AND COUNTY TAX ASSESSOR, ~ ;
ST. LUCIE CpUNTY, FLORIDA:
lhis is my declaration of Domicile and Citizenship in the State of Florida that 1 am filing this day in
accordance, and in con~ormity with Section 222. j 7, Ftorida Siatutcs.
1 was formerly a legal resident of ~yRc ~ W K` and I
(a~r) • ' (s~'a~
residcd at ~``o s s ~Q. V c- . However, I have changed my domieile to
~ (sa.~e saa Numees)
and am and have been a bona Rde residcnt of the State of Florida since r~- day of
--S'~''`~ ~'~R'' ; 19~ and 1 reside at 3~ ps A~A C'ov •2 T •
~ (Street aad Numbar)
~,e /°i ,e c E. . St . Luc ie County, Florida,
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and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State
of Florida. _
(Insert here sny pulieeet faets, such as sate o( ptopettr ot busin~ss. or relinquisAment ot tmpioymeat st to~met
danic7e. temoral ot ha?ily to aew domicile. purcAase, ot home. ete.) ,
• HOMESTEAD EXEMPTION:
ENT'ERING CHILDREN IN SCHOOL. ~ _ _
If entering children in school,
please l~st their names:
`
~ ST~UC~E ~OUM~TI/R Ep
CIERi(~C ~C11tT Cpu~t
pFCOR~ Y~RlfiED
I
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~ ~or 15 3 ~ PM'l+1 -
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I FURTHER CERTIFY thai 1 will register at my local address when the registration books reopen, and
comply with all other requirements of a legal resident of th~: State. ~ .
I FURTHER CERTIFY that 1 have no intention to return to my former domicile, and 1 intend to remain in
~Q T ~i c~ ST . LUCIE County,
,
Florida, permanently.
- - -~Gu-~~ ~LG =-~~~~-t.~~
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~ ' ' SIGI~ATURE
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$wdr~`,t~~nd suC~scfi~ed~betore me this day of _ .
..~e = 19 74 ,3~oS /N~~~.?A fod27'
,r~~ :f A.D. res
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.~~ASlCIERK CIRCUIT COURT ~RT ~i~~ec~ , Florida
.~'j_,{~.~~, - _
B ` ~ DePuty Clerk :
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(To be execuled in dupiic~te ond otiRinal Cded with Cletk CircuN Court. and duplic~te wilh T~s Assessor)
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