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T0 TIlE STATE AND COUNTY TAX ASSESSOR,
ST _ ~.lJr.TF. COUNTY. FuORIDA:
O. R:
Declaration of DoMicile and CitixenshiJloOK
ST. Lt;CIE COUNTY \ t LA. ·
5
304
This is my declaration of Domicile and Cit.benahip in th6 State of Florida that 1 am. filing this day in
accordlln~e. and in r.onlormity with Chapkr 222, Section Zl2.17, Florida Sbitut~s.
I was !ormcrly a legal resident o!____u__~~_l:!~t:if>m_uu._mhu_h____uh_m_______'_h__" _mh. _______~_u_m_hm____m_
_(Cit7) (State)
and I resided at~_2~~ _:r..~_~_~_I"_~r__~_'-_u_m_____um_uh___h _:.__ h __h. Howe\-er, I have chtmged my domicile
(StrMt &lid Number)
to and am and have been a bona fide resident of the Stat~ of Florida since _ _ 1st; _h_U__ day of
__"h___~_~~~mm____m__________h_________' 19_u~9. and I reside uL_u___)'l~Q9___$_L_?1t.h___________m_ _h_._UhUhU____UU__u
(Street &I.d Number)
__UU_____h~!~_...~~_~~~~_____._._______ ______.hm.U _, _.__ ~__h_~_T ....__J~l!_Q~_~_ _ __ __ _____ __ _u___... ___m_u _h_ County, Florida,
<City) .
aJlQ this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in
the State of Florida.
(lllMrt here &.I1y pertinent facta, IUch IU aal, of property or b~ or re!in~uiahment of employmlDt at
former domicile, remonl of family b new domIcile, purchue 01 home, etc.) .
.........
";1:- -7
'!"'il. i
"_...\<~~.-.':~.f."':-; ". .
, ,\.. ....... 1
... . kl~~..^~:;:~~:/.<'r
. . '-'/, " r. L!; r, \ ..
I ',/.' ....
~ . ; ~l I l! I . . ,
ROGER PO:TRAS, CLERK ~
r; '11.-j:' ''l'Il'TV VI ntJ,flA
;J..l,,,. _ ...\.,.. .Jf\llI~
I FURTHER CERTIFY tntl.t I will regiater at my lccal addre8a when the reptration boob reopen,
and comply with all other requirements of a legal reeident of thia State.
I FURTHER CERTIFY that I have no intention tc return to my former domicile, and I intend to re!I1&in
. FT. PIERCE
1IL________________
--------.----- ----,
(Clt7 )
_~!... LUqIE .__u_____________C.oun':y, Florida,
~~___m~_____
JJoMES H. PELFREY JR.
__ ______L_______________
(AdcInoI )
permanentl)' ,
.c.
(To b neeuW fIl ~te ~ orictu1 ew.
"a_ ".lll,. c... P'.:;et Citr. 1l'Ia.
(1erk CIrftfi Court, Uld ftpJ~te wtU: 'l'u ASMNOt')