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DK~llratK.G of DomidJe met C~I+UCIE CJUHiY, H ,',
... ..".... -..... :
TO THE STATE AND COUSTY TAX ASSESSOR,
ST, LUCIE COUNTY, FLORIDA:
Thi. iJ, my dec1araUoll of DomIcUe and CitiwnJhlp in the State of Florida u.t I am mine th~ day in I.ecoi~
Ilnd In conformity with Chapter W, Seetlor. 222,17, Flori(- Shtutes.
I was formerly. lepl resident of
Ninde King Geo.County
(City)
Vi:.':'ginia
State
R n<: I resi.led at
Ninde . Va_
However, I have ('hanged my <'lomi::Ue
(Str~et "nd Number)
to Ilnd am and have ~en a b:m. fide resident of the S13~ of Florida since
29th
December
19 62 , and I rei Ide at 2311 ~o Ind .River Dr.
~Steet and Number)
t'ORT PIERCE, SAINT LUCIE COUNTY, FLORJ~A.
ami this statement is to be taken as my deeiar.Uon of eith40:-ship. adual legal realdence and domicile in the State of Plorl~.
(Insert here any pertinent facts, such as sale of 9ro~rty or bUlinesa, or rellnquuhment of employment
at fonner domicile, removal oi family to new domide, purchase of home, ete,)
App1yin.S for hO~llestead
11.3268
f\ltU ~N,lfREC~\\\)~~m,
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\~o 1 fEB \ 8 pl't \'. 00
\ T R~ S c\.t.\W, V
PQGER Pl'~\\~n~, f\.O\\\l)~
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I FVRTHER CERTIFY that 1 will re~lter at my local addreaa when th. re&illtn.tion hooks foopen, and comply
w;tr: ..11 other requirements of a leia) resident of this State.
I FURTHER CERTU'Y that I have no Intention to ntum to my fOmler domicile, Iilld I intend tQ remP.in in
FOHT PIF-RCE. SAINT LUCIE
Qv/\~ ~" ~. (3~,~
~Mr.I)
wife
Sworn 10 (,nil s:Jbscribed ~fore me thia
18
dayof.~~eb.
,ld 63
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. !:~/j:;(.j:1~t~~ ~"'/:J~ NotAry Mlk
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(To be ::!x~uted in dupllu.t~ ...nd orlrinal fI1~<i wltli~,,~,r~n, aU dDrri;ate with Ti1:: ~)
""".,-, .
ROGER POITRAS
r .r. K CIRCUIT COUP.T
/~~ ~-La6;
day of
z--<<
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