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Declaration
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'T, I ~:.'T C,"'I,.., ",
of Domicile' Qn~J' Citixenship
TO TIlE ~TATE AND COUNTY 'fA-x. ASSl:SSOR,
ST. L'JC ie____COUNTY, FLORIDA:
This is my declaration of Domicile amI Ciliz(-!lship in the ~tatc (If f'lorida that I Itm fil!ng this day .in
:lccordanc~. and in conformity with Chdptcr ~2~, Section 222,17, Florida Sbtlltes,
I was formerly a legal re8iden~ of
. l
i..C~La~j~~ (It..
Lone Jsl;md
(City)
re.':' York
~St&te)
hll.\'c changed my domicik
and I reHidcd ,,' 10 De:nr'.is Street ' However,
~ (Street e.nJ !\umlJer)
to and am and have ucen a uona fide re:;ident of the :-ltall' of Flotlda sincl'
l]th
d.IY of
_ AUf~u~t
19 60 , and I reside ;,t
115 ::0501'.':,: l\Vf: r .:.Jur.,Jet PClrk
: .::itr..et and !\um~r)
Fort niercc
~t.Lucie
Cou:-.ty, Florida.
(City)
and this statemcnt is to be taken as my declaration of citizenship, actual legal residence R:-:U domicile in
the State of Florida,
(Insert here allY pertinent fact:;. s~ch as ~ale of prop!:lt)' or busin..~s, or relinquisllment of emplo}'ment at
former rlomicile, removal of family to nt'''" domicile, purchase of home. ,~,)
~stablishin~ residency
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t1,4R.:L.1 P/1J2'.~S
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I FURTHER CERTIFY that I will register at my local addre,>~ when the registration books reopen,
and comply with all other requirements of a legal resident of this State,
I FURTHER CERTIFY that I have no int~ntion to return to my former domicile, and I intenu to remain
in.__...,,_ ..__..... "Fort, ,Pierc. e". .....,-',
(City)
"..,St...Lucie. .... ," .." ..County, Florida,
o."~'__' ,~u~ ..JJ2..~ _m__" 0 ... ..,.. , /
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( vne)
Emil A Hendersoh
-.---..---------------.,
pennaneI1tly.
(Addre8! )
Sworn to and subscribed before me this..,..2l,. day of
, :.~:/.::;~ ~ :,;' ; :'~ ~:';'
--4" ___1< r,ch,oo..m"...' ,0.000...,__,_...,___, A. D. 19___61
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My ecmmiasion expires,___ ---~.~,~,~...~~!,-~,~.~~-,--- "-~' ,.,.
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(To be n~ted in duplicate and oririnal filed will. Clen: Circuit Co~. and dUJl\ic.t~ with Tax Auessor)
Ro_" 8UDOIY Co., P,ant t'\!y, Fla.