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Declaration of Domicile and Citizenship ~ 3
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TO THE STATE AND COUNTY TAX ASSESSOR, ~~3Z~
_ ST. LUCIE CpV~y, FLORIDA:
'I~is is my declaration of Domicite and Citiaenship in the State of Ftorida that I am filing this day in
accordance, and in confonnity with Sectio 222.17, Florida Statutes.
1 was fo~ erly a legal resident of ~r~ , . ~ and I
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resided at ~ /~-~a~~ . However, I have changed my domicile to
r ' (St~eet Numbst)
and am and have been a bona fide resident of the State of Florida since day of
, 19~ and I ceside at i~ n~- ~ ye
, (SMet ~ad NumEer) '
~ r~ St . Luc ie County, Florida,
, ~ - (t~~r) _ ~
and this statement is to be taken as my_declaration of citizenship, actual legal residence and domicile in the State
ai riorida. • _
(lasert Aere any pertineot [acts, such as sale ot Pwperty cr businas. ot relinquahmeat ot sa~ployment at former
danicile. ~emoval ot tamilr to new domici~e. Purchase ot Aaus. ete.) .
• HOMESTEAD EXEMPTION:
ENTERING CHILDREN IN SCHOOL. _
If ente=ing children in school,IF~
please list their names:
~~S fh }~~„~~t h r»a ~t_ s~ _
s~~~ *f'~
t~c_s~ ~
~tftt~l~.~ 1~iE~' ~i~C
~ - ,Y
_ ~ ~ , T~
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.
" 1 FURTHER CERTIFY that I will register at my loca! address when the registration books reopen, and
comply with aU 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
~01~T ~~T ~/.(C~~_-~~,~ ~ ST. LUCIE County,
Florida, permanently. «``r) ~
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- V .~s~v . oG~ S IGNATURE
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~ '''t~$ ~~be~before me this day of
.,~.sr ~-k% . ~i
• ; 74 •
~ ~ • A.U. 19-_~ ~ /7' fe
-Pra3.Z g r~"""" _
R CIERK IRCUIT COURT lJ~ J- ~~r, ;o ~ Florida .
gy ~ C` puty Clerk
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(To !e xscuted in duplicate and ori;inal tded wilh Cierk Circuit Coutt. aad duplasts with T~x Assessot) rL~ ~p Q) '
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