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Declaration of Domicile and Citizenship
TO THE STATE ANU COUNTY TAX ASSESSOR. ~4~s
ST. LUCI~ Cp~~y~ FLORIDA:
This is my declaration of Domicile and Citizenship in the State of Florida that I am Rling this day in
accordance, and in conformity with Scction 222.17, Ftorida Statutcs.
1 was formerly a lega! resident of ~R~ ~h~ o and I
' (staa)
(Citr)
re~d~ 8~ ( 3 ~A~~e~e.~.F i4vC . However, I have changed my domicile to
. (Strstt a~d Numbes)
and am and have been a bona fede resident of the State of Flortda since day of
d u , 19~., and 1 reside at y~~. ~ wN~'cu•
~l~f _ .
• , ~str~s~ ~aa N~wber)
~~T" . ~ L ~~;g~ ~ St . Lucie ~ County, Florida,
(u~r) . - ~ . -
and this statement is to be taicen as my declaration of citizensttip, aciual leg~l residence and domicile i~ the Stat~
of Florida
(lasert hete sn~ pertineot [acts, suc6 as sale ot propMr or business. ar r~linQuishmeat of tmploYm~ut st famet
domicile. removal of familr to oew domitile. Purchs~e of home. etc.) -
OL• HOMESTEAD EXEMPTION: ~
ENTERING CNILDREN IN SCHO . ~ ; .
If entering children in school, -
please list their n~mes:
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fiLfO AN~ RECOti~EO ~W
iT. UfC1E COUNTY FLA. ~
. R4CEr F~1lTtUlS ~
CIfRK C'3Litlt C4URT
. RE~^R~ VEo~iiED~..
O~C 1 3 22 P!l'7~1
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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 my former domicile, and I intend to remain ir?
~o ~2T ST L uc: ~ ~ ST . LUC IE , County,
Florida,; ~ ently. «'~r) _
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; g~~.~'~~,~~ beFore me this day of
i•.. . ~
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~a~'`~~! , A.D. 19 7 4~ r ss
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ROGER POITRAS, CLERK CIRCUIT COURT , Florida
gy r/?G~ puty Clerk , -
(To 6e culed io duplicate and oriaina! t'~led with Cletk Cireuit Court. ~nd duplicate with T~x Asseuot)
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