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ib~i 20 ~458
Declaration cif. OIMntMtr.<ro~ Citizenship
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TO THE STATE AND COUNTY TAX AS..~,
St:.. T..ud.
COUNTY, r-lORIDA:
Thll i, my ctec=aration of DomIcUe end Citizenship in the State of Florida that I am filing thl, v.y In 6<XOI"dance,
and In confofmlty with Chapter 222, S<<tlon 222.17, FIoricH Statutel,
I wet fornlerty a .1 ....ident of ______. P~eaafJD.trllle..n_.. .___.o__.______ , Jlft)(_J..e.r8.e~-------
(CIty) CSt...)
and I r.alded aLn_ _.s.O)__Cb.Jtetn.ut_.str.e&--_.__~_______.____, Howe\08f', I have changed my domldl.
CStrM1 ..... NumMr)
to .nd am and have been a bona fide r.aldent of the State of Florida lince__. -.lOth__________ _u__n_ _day of
___u_.. ___ _Q~~Ob_tl~___u___.._____, 19 ___6~ and I reside at .. _____.333.3._Feder.aL.HL-w&y____u__'
(SeNet MId Number)
___,_ _____fort _Pieree~u__u_u_ _____uu, --------------St-.1.uc-1e- ______u_ County, florida,
(CIty)
and this It.tament is fo be taken .. my declaration of dtizenship, actual legal residence .nd domicile in the State
of Florida,
(1-.. heN ..., pertinent fllCtl. wciI .. .... of PfOP'I'tY or IIwlMN. Of rellnqu....._lt 01 ....10(11I8I11 .. -- ......
--' of fwNly to __ ....., ~ of ...... IIIC.)
9Eotering Melvin Johnson in the 2nd grade
· David Johnson in the ,. th grade
991.74
f\lEO f1.NO RECOROEO
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ROGER _ 1"-'\'\ \' " ;;
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, RJRTHER CERTIFY that I will rogls"" .t my Ioal 8ddreu when the registration boob reopen,.nd comply with
ef' other requirements of . legal resident of this State.
I RJRTHER CERTIFY th8t I have no intention to return to my former domidle, and I Intend to remain in______
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(OIy)
perm8Mntfy ,
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Berni e J oij{lb:
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Sworn to and lubsCTibed before me thll_, _ 17~.:~>;~;;~~X:i~"'.~~~,!)-~~!'----------u---, ;9___~~
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ROOER POITRAS '. /~..,;-~~~., C' . ^'\~;';\
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