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Decloration of Do~~~I~~~~~~~A nship
TO THE STATE AND COUNTY TAX ASSESSOR,
COUN~If, FLORIDA:
This is my declaration of Domicile and Citizenship in the State of Florida that 1 am fi0rp this day in ecoordanos and
in conformity with Chapter 222, Ssdion 222.17, Florida Statutes.
. Pu Val _-~ --------=--------• --- ----- N ~1± Y9~.k---
was formerly a legal resident of_________ n_----1(~rt Rut.)
and 1 resided at ___-___HS?~~rt1__vj..@!!_ ~~tcaY.-@S•- R,- D,_.~Z _------• • However, I have _d:anged my ~klle
Rtr.N and t+hwnber)
to and am and have been a bona fide resident of the State of Florida since______~_____------------------- day of
November 61 4409 Metzger Road
-------------
----------------• 19-----• and I reside at -~--------------- - =---
---------------------------- Rtreet and tirwnbert
Fort Piercd St, Luc ie _____ ~,nty, Florida,
------------------------ccnr~ --------------
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Florida.
pneart hen any pertinent fsc», such p MM of property a businew. w nlinquiahment of emplcYmen- N former domicile,
removal of family w new domkile, purchase of home, etca
:.i..
Applging for homestead
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BOOK
1961 JA~~ -8 qM 10:55
$RO UCIE COUNTY FLORTpA
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I FURTHER CERTIFY that I will register at my local address when fhe registration books reopen, and comply with all
other requirements of a legal resident of this State.
1 FURTHER CERTIFY that I have no intention to return to my former domicile, and I intend to remain in
Fort Pierce
------- ------ - ------
- - - -- City)
permanently.
--_ St. Lucie - -- County, Florida,
~~~
l~~ ~~
---------------- ----------------
("""'~ Englebrecht
Grace_ dc__John ____ __ _ __
Janus 62
-----_day of ----------~=-- -- . 19------
Sworn to and subscribed before me this _ _____ g ---.- - - - ------ -- ---
Roger PQitras, _ ~lsrk ---
---------------------------
- - -- -------- Notary Public
RCiGER POIT ,_CL'ER,K/CIRCUIT COURT
~~~ ~~~~u~-~f_ _-- - -- ----- D.C. My Commissiop expires ------------ -------------
Y - -- - -
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