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Declaration C)f.-Domicile and
S:. tUC\E COUNTY, flA.
Citizenship
-- -... -----~.
TO THE STATE AND COUNTY TAX ASSESSOR.
_____-St.. t.n~1 $
COUNTY, 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 was formerly a legal resident of
Scrantou- (Thornhur.~ )
(CIty)
_P.enn
(St...)
and I resided at
St.ar Route_Gouldsboy.o
(Strwt ..... Nuoftber)
However. I have changed my domidle
to and am and have been a bona fide resident of the State of Florida since
20th
day of
.. - July
_ _ _ ._ . 19 61, and I reside at _2701. So _ 26th.- _sueR - .-
(SttMt ..... Nuoftber)
Fort Pier~e
St. Lucie
. ___ ._ _ _ _ _ ____, ___ ._.u __ .t___._.. --. -.. - - .
_" _. . _ _ County, Florida,
(City)
and this statemont is to be taken IS my declaration of citizenship, adual legal residence and domicile in the State
of Florida,
(1-' ...... ...,. pertinent facta, IUCh .. ..Ie of property 01 ~, 011 r.l~nt of emp!o.-" .t *- doonicile.
.-.1 of fMftiIy to _ cIomlclle. pum- of ~ lIk.)
Ent.ering Richard in the 8th grade
9i~53?
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FILEO AND RECOr.OEO
IN~,L,":J.K
190' AUG 22 >>7'1'0: 4 I
ROGER POITRAS.C: ....
SLlUC\E COUNI1. f lUl\.dA
"e ~~
I RJRTHER CERTIFY that I will NQIs_ .t my local ~r" when the reglstr.tion books reopen, and comply with
ell other requirements of . Isgel resident of this Sf....
I FURTHER CERTIFY that I haw no intention to return to my former domicile. .nd I intend to remein In______
F -
___ __o.r.t_-Pier.ce---------------------- -- -
tcJIyt
permanently .
___ _ ~1t....L.\lci..L____________h__ County, FIoride,
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=_~_::_=::_=:_:_~~~________~~_~-- doy 01 Z_~~~;(~~~~-~--~-~:~~~~~~l
ROGER POITRAS, WRK CIRCUIT COURT Not...., Public
.'. ':::&. PubbC, S'-&e 01 FIOnde .t laf9i1
By ___________________________________.:._ D,C. My Commission .xpl.... -::....';l~::=r"~~~~. Y.
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