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ST. LUCIE COUNT~- FLA.
Declaration of Domicile and Citizenship
TO THE STATE AND COUNTY TAX ASSESSOR,
ST. LIICIE COU~y~ FLORIDA
This is my declaration of Domicile and Citizenship in the State of Florida t .at : a;r, ::li:.g this a•y '-^.
accordance, and in conformity with Chapter 222, Section 222.17, Florida Statutes.
I was formerly a leas] resident of______CI~YELAND--------------------- -- ---------------• ------------4,IIIS2______._____--------
(ciq) -- ------ (st.te)
and I resided at_1.2~ K~@4thSt~___-_-____.__------.--_-_- - - However, I have changed my domicile
i9L3's~t ~ Numbsr)
...... ~ _
to and am and have been a bona Sde resident of the State of r'loritia since ~~ ~« - -.. ia, :;:
ltereh __ ls_~_, and I rceidt: at__-170_ A~izana_Ataat~-__-- -------------------- --------
-- (8treet and Number)
lrort Pierce 3t•Luc~ie --Cc;:aty, Florida,
- ----------- ----------------------- ------
------------------ - -
_ (at~~
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in
the State of Florida. ~ ~+
former domkilsy r moral of tamil7 o ne do ~ ile~pnrchue of bome,e~te~~Quisbment of employmeat at
915 ~ •~
;:
~~'~`al:u~ ~ 'K
lgbl JAN 18 N1 ~ 20
I' iGE2 POITRdS, Ci`~' .~~
nn.r AA11 \ITY CI :'1.
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.~ ~
.r. - '- ~ ~
_ ~t : .!' 1
:.,., : 'mot ~
I FURTHER CERTIFY that I will resister at my local ~addresa when the reaistration hooka reopen,
and comply with all other requirements of a legal resident o! this State.
I FTJRTF.ER CER?'La'ti' reset T hAvp „o ints+ntinn to return to my former tiomicaie, ante 1 intend to remain
~ortPisroe
permaneatb-.
(cxtn)
i 3
Sworn to snd sul~lll~, _ f ~ ~; ~ , ~
Jaguar ~'-`'~ ~. ~ - ~' =;~:'
1~. ..
~~
_ St .Lucie ___.~--_----_---__-_--County, Florida,
~_ ( ~
Xard J. era!
~_dan of
,D. 19 61.
(Te De ~eoad is a,~icaa sea eri~i irl~a witi a.arlc c~it Court. sad daaua-a with ~ Ae..seos)
ass.. ~eeoh t,Y» Meat Clq. lla.