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D~~I~r ~~~on of Dor~niciie ~nd Citizenship
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1'U 'flll: STATI: ANU ('UUN7'Y 7'A~ ASSI:SSOR,
_ ST. LUCIE _ GOUN7'Y, [~LQRIUA:
TI?is is my dccl.U.1I1U11 OP DOfi11C1IC and Citizcnshi~i in thc Statc of Tlorida ih:~t 1 am f~ing this day in
accorJancc, and in canformity with Scction 222.17, Florida Statutcs. ~
1 wa~ fornicrly a Icgal residcnt ol' ~ , and I
(Citr) (state)
residcd at _ . Howcvcr, I I1~V changed my domicile to
(Strcet and Number)
anJ am and havc ix~n a bona fidc residcnt of thc State of rlorida sincc day of
_ 19_2,~_, and 1 residc at ~ Q ~ ,
(Street and Number)
~~~~~_~~Q _ St . Lucie County, Florida,
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~cti~~ )
and this statement is to be taken as my declaraiian of citizensl~ip, actual legal residence and domicile in the State
of 1=lorida. -
(Inscri hrre any {~crtinral facts, such as wir of ~ruperty or busi~ess, w relinquisl~ment of employment at former '
domicile, remo~•al of family to new domicde, purchast of ho~ne, rtc.)
Er~TERI;IG CHILDRETd IN SCHOOL: HOMCST'~AD EXEMPTTOr1:
If entering children in school, ~ ~
please list their na~nes: ~01~rO~
~
f
i11.ED ANp RECOROEO /E `
St. ROCER POItRA8 L~ ~ Cr i
CLERK CIRgUIt COURT ~
RECORD VER;FJfp 0' 3
FEA E~ 2 36 PM'1 }
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1 FURTHER C'ERTI(=Y that I will register :it my local address ~vhcn the registration books reopen, and
comply ~vith all other requiremcnts af a legal resident of this State. ~
I I~URTNER CCIZTIC'Y that 1 have no intcntion to return to my former domicile, and I intend to remain in
~ ,p ST. LUCIE
/ s,t1~~ a , , CountY,
Florida, pcrnianently. t~'"•~
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~ ~ . ~ _ S IGIIATURE
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~ Sworn to~~if~l,s?~Uscribcd bcforc me'this 9` day of
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~''r'Y.u-Q~ , A.D. 1 7~.
i ing ress
~ P.OGrR POITRAS, ~ CLF.RK CIRCt1IT COURT , I'lorida
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~ By ~._.2~-~ Deputy Clerk . . .
~ ~Tu be e~ecuteJ in du hcale and ori~inal ~i1eJ ~+ith `~p~ ourt s with 'Cax Assessot
~ ~OOx~ Pll~f ~
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