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Declara~cor~ o~f ~~r~ics~~ and Ci~iZenship ~ -
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'1'U "f1ll: S'f~A"ll: AND COUN'il' '1:AX ASSI:SSUk, t
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ST. ~ 1~UCIE COUN7'Y~ F~ LORII)A:
Ttiis is my dcclc+ratian of Damicilc and Citizcnship in thc: Statc af Florida that 1 am filin~ this day in
accor~l:~ncc, :,~~d in conformity with Scrtic~~~ 2''2.17, Florida Statutcs.
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! was fornicrly a lrgal resideni ~f _~~~~d~CL , - ' and 1
~ (cilr) (state)
r~sidcd at _~.ll~ ~ Howcvcr, I have changcd my domicilc to
( eet snd uml.rr)
and ~,m and havc bcen a bona tidc residrnt of tltc St~itc of Florida sinc ~ day of
, 19~, and 1 residc at G
(Slrret a~d Numbu)
~ Gl,~ici(, St . I.ucie . Gounty, Florida,
(c~~ s• )
and this statement is to be taken ac my declar.~tion of citizenship, actual legal nnsidence aizd domicile iij the State
of Florida. ~
(Insert here any pertinrnt facls, such as s~le uf properly or husiness, or reliriquishment of employment at former
domicile, rrmu~al uf famity to n.•~v doniicile, purchase of hume, rtc_)
E?IT~RI;~G CHILDREt: IN SCHOOI.: HOMCSTEAD EXEMPTIO~•i :
~f entering children in sch~ol, ~ t
please list their nancs:
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E QE
~~~t~uCt~ COUM~ F~
ROC~-~ POITfUs
RE Oaa VER1F f0 C~~
- ~ t~ 101 PN'ZS
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1 FURTHI:R CI:KTIFY lhat 1~vilf rcFistrr at my local address ~vlicn the reoistration boaks reopen, and
~ cc~m~~ly with all othrr requirements nf a Iegal rrsident of this State.
~ I FURTHEK Cf~RTIFY that 1 ha~•e no ir.tention to return to my former domicile, and 1 intend to rcmain in
~ ~ ST. LUCI~
~ COUnty,
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g I~luri~a, pennanrntly. cc~",~~
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_ . - SIGi~TA'I'L:ti:,
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3 Sw~in tu a?.~~i~i4~tcrits~cl l~efore mr ti~is ~
o._ day of
~ f~=----- A.D. l~l-~ r~
~ - - ' ~ lr.g c.~~ ~ss
-.~tQCirR --P~I~ ~ CLER!! CTR ~1 T COURT
~ • - _ , Fl or ida
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~ By~ „ - G~~~l cput;y Cl~rl;
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'Y (To t?e esec e:! • ' . . •~~,.:mJ ori}•~n:~l filcd wilh ('Irr~. ('ircuil Cnutl.: -iir~le ~vi!t~ 'la~ Ac~ras~N)
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