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Declaration of Domicile and Citizenship:, T, l UClE (QL'kiY, FL A.
TO THE STATE AND COUNTY TAX ASSESSOR.
St. Lucie COUNTY, ~RU>A:
This ia my de('}a~tion of Domicile and Ciwf1:wship in the State of }''1orida that I am fllinJ this day in
accorfianc.e. and in conlormlty with Ch!lpter 222, Seeticn 222.1"7, Florida Sta.tutes.
J WIiS formerly a l~p.l rt'sident oL______C.Qv:~l}gt9n----.oo...oo----- ..,._______________..______,' ___ooJ\~_t:..u..~~.__.._______.__._
(City) . (State)
and I resided at.. ._ 19.2) J.J~~.._?~r_e,~~,________.oo. ,__ ._. However, I have (;hanged my domicile
(Street aDd Number)
to and am and hr..ve been a bona Me rE'8irlent of the State of Florida since 3 --. .h'" day of
Marcn 61. '.06 N. 2nd Street
_.'..__,,;;_________________________. m _____...;;;.'__' 19__.___, ~~d ! r AlrlP. n t n--------------.-----m---(.s~-t-;~~X N-~;;~~;.------- ...---.---,---..--
Fort Pierce St. Lucie F'l .
___________.____._oo_nn_m_____oo______________.um___n_________.___., ________oo_____ _ ______________ .m____ ___ --- _n ______.m OO" County, orldn,
( Ciq)
and this statement is to be taken as my deelaration of citizens!tip, actual legal residence and domicile in
the State of Florida.
(lllMit here lUly pertinent facta, luch lU ..1. of property or blllineas. or relinquishment of employmont at
former domidh. removal of family to new dor.licUe. pu~h..e of home. etc.)
En~erin Mark Edward Storck in 1st Grade
-92905
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ROGER POITRAS, Cl[qK
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I FURTHER CERTIFY that I will register at my local sddres8 when the registration hooka reopen,
and comply with all other requirements of a legal l"e8ident of this State.
I FTJRTIIER CERTIFY that I have no inte-ntion to return to my former domicile, and I intend to remain
Fort Pierce St. Lucie
:~::;~----.------(Cit7) -------------------, --:--- --7J------------------.---.county, Florida,
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LOllis Storck
------------------------ ---.----------------
(Addreu).......,
Sworn to and subscribed before me thiam___~.day o! _ <.::."::;~'~:~.. .~,
J:.. '"-' ,.- ','" ..~ ..: '..,'
Mar~_.-._- . A. D. 19_.\'-1 . I ..," ','.f'- .......
Roger. P_,,-l ~ras! Clark 0 f Cir cui t co=t\:i_(},~ :J;:,:~:}i~ i
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~1IIl~h<<)wo,.f~.M(By: ~/d~ IJ t! . :"'" ":/'''~:~:''
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(To be ~~ !It du))~te and oJiPW 6JtICi wtth a.n Cirnit Court. ad d\...ueate witk Tax Aueuor)
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