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Qeclaraticn Qf Domicile and Citizenship BD'•R 5Q iA(EJ~.~2
TO THE STATE AND COUNTY TAX ASSESSOR,
3T. LUCI$ COUNTY, FLORIDA:
~,
This is my declaration of Domicile and C[tizenship in the State of Florida that I am filing thin day in a,cord:u-ce
and in conformity with Chapter 222, Section 222<17, Florida Statutes.
I was formerly a legal resident oL- Akron
[city)
Ohio
state
and T residEd at 222 Twin O9ks Road ~~ However, I have changed nay domicile
(Street and Number)
to and am and have been a bona iWe resident of the State of Florida since 1$t day of
October 19 62 ana I reside at ~11 PoA1sr Ave, River Pk
• [Street and Number)
F'UFtI PIERCE, SAINT LUCIE COUNTY, FLORIDA.
and [hls statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Florida.
(Insert here any pertinent facts, such as sale of property or business, or relinquishment of employment
at former domicile, removal of family to new domicile. purchase of home, eta)
Establishing residency
11_ossl
,.
_ ~~ ; -~
•~ •~ •~ J
. '~ ~ j
f 1lED APID RECORDOOOK
IN_~
1961 NOV 26 PM 2: 17
ROGRR POiTRA F't,~RROA
ST, IUCiE COUNt'f, D
~v r
I FURTHER CERTIFY that I wW register at my local address when the registration books reopen, and comply
with all other requirements of a legal resident o2 this State.
I FURTHER CERTIFY that I have no intention to retur to my former dor 'Ie, and I intend to remain in
FORT PIERCE, SAINT LUCIE COUNTY FLORIDA, permanent ~~~~--1
G/ L9G1~8rQ~efl/ _
1~) [Address)
26t1a •.q r•' ~''•~,'- I~ovember-
Sworn to and subscribed before ne this tL 'day: p~•; - -- ----, 19_•_._ Qa
• • • ~ , . r •., w> .,
R POITRAS t-' ~ . ' - °~ r ___'_.:.~~.._._..._~ --
CLERK CIRC IT COU-R-,rT.~- _=~ i ~ ~ ••~ , .; . • .. "" • cs ..' Alotary P~ibiic
,.
[To he e:acated in duplirato sad orl~al filed with CLea3c (`=..roit Court, and dnplicata with Tax Assemwr]