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"I~U Tl~l~. S'IA"1'I: AhU ('OUNTI' 'I~AX ASSl:SSUR, • ~
--ST. LUCIC-- - ('UUN~'Y, I~LOIZ11)A:
"ll~is is i»y cirrl:iratio~~ c~f 1)~micilc arnl ('iti•r.rmhip in thc Statc uf I~lorida ihat 1 am lilin~ lhis day in
accor~lancc..md in confurmity with S~ction 2?2.17, I=lorida Statutcs.
1 ~vas fornirrly a Ic~;al residcnl of _I~1.1-~A~~ - . ~E`~ - ~G~Q~L~_ and 1
(CiIY~ (S le)
rrsicird at _~-~.__~Q~~- . Howcvcr, 1 havc changcd my domicilc to
(Slrcrt and NumAcr) i
.uid am .md l~avr bccn a bo»a ficlr rrsidcnt of lhc Statc ol' rloridu sincc _ day oi' ~
d_~C~--------- , 19_~_~, and 1 residc at __~!.S - -
(Slreet and Numbcr)
-/C `?-l _ - ~ __St ._Lucie County, Florida,
F'1~e~,~------
(r~~~•)
.:nd this statrmeat is to br tai:cn as my declaralirn~ o( citizenshi~~, artual 1.•gal residence and domicile in the State
of F~lorida.
(Inseri hrre auy pctlinent facis, scch ac sale uf pruprrty or businrss, or relinyui~hment ot employmcnt at turmer
domicilc, removal uf familY 1o nc~v Jumicilc, purchax of homr, ctc.)
E;3TEkT*ZG C~IILDRE!~I I~d SC:iOnL: HOi•tESTEAD ~\CMPTIO'~i : ~
If entering children in school, ~
please list their nanes:
~ll~8 :
. I~~EQ ~~r o ~;p~p~~
~UC1E COUINTY -
Cf.ERK ER FOITAA~~ ,
RECORO YE
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~ 1 FURTl1};)t Cf:RTIE=Y th.+t 1~vill resistrr .it my local address whrn the rcgisiration books rcopcn, and
comply ~vith all otlter requirements of a Ieg:?I rrsident of tltis State.
1 FUR7'I1GR C?:RTIFY that 1 ha~•c no intcntion to return to my fonncr domicilr, aud 1 intcnd to rrmain in
~ ST. LUCIE------
~ ~ r , ~ , Countl~,
~ e,n~~a~)cntl (c~~~~> -
~ f~ lorida;• p • y. •
~ O ! . ' ' / ^ '~r".,~~
~ . . - - -
~ ' ~~l Vincent Kowalcz
Y
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~ ~ - S IGIvATU:L:
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~ S~~~t~r~( tQ,.:iii~ siSl~scribcd l~cforr mc this 3---- day of
~ --Febrtlar~ - - - A. D. 1 f ~
~ ~ai i~~g u r~ss
~ 1tOCF.R POT'i'R11S, CI.ERK CI}:CUIT CUURT ~ r~,;--;f~a
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~ n~? ncput}~ Clerk :
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(To bc excculrJ in duphca~•• 5nd ~,~i~n.:~l filyd ~~ith ('Icrh Cin~uil ('owl. J Jupli:alr witl+ lac Ac~r.vx)
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