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W~lt.er V. Herman
ST. LUCI[ C(IUHTT. FlA.
Declaration of Domicile Gnd C.tiz(;nship
TO THE STATE AND COUNTY TAX ASSF..3S0:R.
STgLUCIE OOUNTX, FLOBlDA:
'..l'hia ~ my declaration of ~ and ,CitizeNhip in the State of Florida that I am filing this day in
aceordlu.,ee, and in conformity with CMpter 222, Sflction 222,17. Florida StatuU!.
I wu formerly a lep.l reaident of___~.T__.~tRQ~_~[~Jl_u---~- --., ~~~~1:Y AN~~.._____
(Cttr) (atu.)
and 1 resided At._______JtJLiu..3m-----------..---.---------------.---.-.., Howet't:f, I have chanKed my domicile
(StrM\ aDd l'~umber)
to and am and have b-...o.en t. bona fide reaident cf. the Sta~ of Flori? j since..l2th..------.-----.---..-----.--- day of
_..________.N_9V.emP-~~.------.---.--, 19__P.., aLd I reai~ at..__.1li__Tum.blj.IL.K11n&...R9:a.d.--------------:..---.
(Street aDd NUJIlMl-)
__u_.~.Q!:Vi.~!"_c;!_____...__________, _m~.~!.~uc&~____m'_______.___._.___._ ,,__..C~unty, Florida,
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and this statement is to be taken as my declaration of citi...en~hip, actual ICi81 residence and domicile in
the State of Florida,
(lnMrt here any pert:.nent fact.al, Il:eh U ul. ofprop"'rtJ Of buaineu. Of relinquiahment of emplo)'m..t at
fOJ'1Def domlcfl-. nmonl of funD,. to new domicile. purehut of bo~ ..)
92790
FILED AND RECORDED
IN~OK ~/
195: ~iAR -2 n:j,lo: 43
ROGER POITRAS, CLERK
S1. LUCIE CCUNn. FLORiOA
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I FURTHER CERTIFY that I will repter at my local addreu when the reptration hooks reopen,
and comply with all other requirements of a legal realdent of thi8 State.
I FURTHER CERTIFY tht I have no int!ntion to return to my former domicile, and I intend to remain
Fort Pi8l'ce St. Lucie
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pennanent.i7 .
County, Fk>rida,
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, (Naae)
Wal~er V. Herman
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sw.,~~~"IL'M' ~ !>I1ore me th1a_~day of
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;~ be QteQi;od In L~!h1:ll aDd orlaiD&l ANd with t."1ft ~ ~-.t. ~ c!'4plieate with Taz AaMHn)
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(AcIdreu )