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Declaration of Domicile and Citizenship 'I. Ii.
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TO THE STATE AND COUNTY TAX ASSESSOR,
St. i.ucie
- nCOUNTY, FlORIDA~
This is my declaration of Domicile and Citizenship in the State of Florida that I am filing this day in accordance.
and in conformity with Chapter 222, Section 222.17. Florida Statutes.
I ...., formerly a leg41 resident of
Bessemer City
.Korth Ca"':)l'na
ICity)
I5Ie'.1
and I resided at
110 ~. Inman Avenue
IS',.., end Nurnbe<)
H,owever. I have changed my domicile
to and am and have been a bona fide resident of the State of Florida since
17
day of
J\ugust
, 19 61 ,and I reside at
3050 Sunrise Blvd.
IS',.., and Number)
:!:"ort Pierce
St. Lucie
(City)
County, Florida.
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State
of Florida.
(lnMrt her. .ny per'inenl facto. auch II &ale of property or buair..u, or relinqui........., of empIoymen' .1 former domicile,
r.mov.1 of f.mily '0 new domicile, pure"'" of '-. ele.)
Enterin~ two sons in Junior High School
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I FURTHER CERTIFY that I will register at my local address 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 intention to return to my former domicile, and I intend to remain in
Fort Pi8rce
;:it. Lucie
County, Florida,
(City)
permanently.
'.
au~, a, &g'&'~~4/
(Name)
~.J
~
X Claude A. Collins
.' .
...
(Addr..,,)
'" . .' ~~
Sw<x~.~'~"ubW!b,ed before me this
. ....:.: ~..~. .
18
day at
;'ugus t
, 19
61
By
ROGER)).oITRAS, ClERK CIRCUIT COURT
~d~
Notary Public
D.C.
My Commission expires
(f. .....ee..... .. Hpllce'. .... ,,"-i...1 filed with Cieri< Cin"iI C..rt. ..... ......Iicete ..... T.x "-)
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