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Oaclarahon of Domicile and
Citizenship
~O~K 20 PAGE 3~8
ST, LUCIE C8UNTY, fL^.
TO THE STATE AND COUNTY TAX ASSI:SSOR,
_~A-1uc1e
COU/,\'TY, FLORIDA:
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This is my declaration of Domicile ~nd Citizenship in the State of Florida that I am filing thil day in <<corda nee,
and in conformity with Chapter 222, Sedion 222,17, Florida Statutes.
I was formerly a lega: relident of
Beau!'ort
South Carolina
(Cltyi
150 James Street
(SI...)
and I resided at
Box 8~.
However, I have changed my domicile
(SffMt and Numbe<)
to and am and have been a bona fide resident of the State of Florida sinee
9
day of
October
,19 61, and I reside at
506 N. 2n~_~~re~t
(Str..1 and Number)
. St. Lucie
Fort Pi. erca -
(City)
and this statement is to be taken lIS my declaration of citizenship, actual legal residence and domicile in the State
of Florida,
County, Florida,
(Inaert her. any pertinent f._, we" .. ..I. of propa<f)' Of' Mlneu, Of' r.ilnqulshrNnt of emp~ .t for...... domklla,
r_.1 of f....ily to ...... domklla, purd\eM of '-'a, etc.)
Entering one child in first grade
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99141
FILED ANO RECORDEO
Official Record
IN ___...,____,.-__BOOK
196i OCT I 6 PP 2: 04
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I FURTHER CERTIFY that I will regilter a1 my local address when the regiltration books reopen, and comply with
all other requirements of a legal resident of thil State.
I FURTHER CERTIFY that I have no intention to return to my former domicile, and I intend to remain in_.. - -__
Fort Pierce St. Lucie
_. _ _ _ _ . _ _ County, Florida,
(City)
permanently,
_~7JA..>~ <7~~",,~.Gl~
_ _ _ ~_ _~ "-~~"_Q.1@.__':r f _ _.~_~ ~y, _ J~~~_.)
(Addr.-)
Sworn to and subscribed before me this.
16
day of _______9_c;.t!9A~r__ __________ ___, 19_..{>1
ROGER ~S, CLERK CIRCUIT COURT
By ___(k___~~--------__--h D,C,
Notary Public
My Commission expires
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