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DeclarationS TofJtl!J6mltlleF ~nd Citizen~hip
TO THE STATE. AND COUNTY TAX ASSESSOR,
St. Lucie
'__H' _.COUNTY, flORIDA:
Thi, is my dedaration of Domicile .nd Cilize!'\Ihip in lire State of florida thaI I 11m filing this dilly in acCOrd!lrlC6,
end in oor;fot-mity with Chllphtf 222. Section 2n,17, Florida 5ta!vte5.
I was formerly.. legal relident of HAzard
Kentucky
(St.",)
(Cay)
and I rMided .t
Baker Avenue
~ ltfId ~)
However, I hove chooged my domicile
to and em and have be;tn a bone fide fMident of the SII'e of F!oridll since
2
day of
July
19 61:, and I rhide 8t
102 W. Prima Vista Blvd.
- .~
~"""I end N......ber)
Fort Pierce
St.. Lucie
C(~nty, Florida,
(Chy)
and this IHt.ment il to be t.ken as my declll6tion of citizenlhip, ectual 18i;lal r.liden<::e and domicile in the Sfate
of Florida,
(1_ hlrr. ...., ~t '-' ....dI .. HI. of pi'Op<<fy Of' boosl_, Ol' ,.!irlqulthm8nt of *""Ploy......" .' .Of.....r domicil..
_I of f....lty 10 _ .....lcil.. ~ of hocM. Gok.)
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, FURTHER CERTiFYm.., I will regilt'" &1 my lot...; addr~u wh41n tM regiftrlStkm bool<.~ reopen. lind comply with
fill oi'he-r reqvin'f'l'lenl1 of II leg.' r.,id9nf of ",b. $fl'fIe.
I FURTHf.R Cf.fHlfY thet ! h"w no int(fffltlen1 to r<<turn ~o my fOfm4tf domicile. ltnd I Inter.d to flil!'r',in in_
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, \9, 61.
Sworn to IlO.1 'tljb!Kd~Mfuffl ..n-t 'hit
ept~\'!b~r
I'k>tary P-ublk
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