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Declara~.~~~.~Y~~Citizenahip
H) TilE STAT}>; AND COUNTY TAX ASSESSOR,
:-:T, LuCIE COUNTY, FLORIDA:
This is my declaration of Domicile and Citilenship In the State of Florida that I am ~iling this day in accord&l1\:e
and in l'llll(ormity with Chapter 222, Section 222.17, Florl~. Statutes,
MAYODAN
I was fOrJlll'rly !l legal resident of
(City)
N. C.
State
;111 I rl'~ill('(1 at
401 N. 3rd Avo.
However, I have changed my domicile
(Street IIml Number)
tt> ,n.l 11m and Il/\VC b('cn a b:lIla fide rC!lident of the Slate of Florida since
1st
day of
SEP'fEJ..BER
l04 N. 39th St.
1:) 62 . ami I reside at
~~
(Steet anti Number)
FOHT PIERCE, SAINT LUCIE COUNTY, I-'LORIDA,
11..,1 lhi, ,tatl'ml'nt l:< to be taken as my declaration of citizenship, actual le~al residence ar.d domicile in the State of Florida.
(In~('rt here any pertinent fact!l, such 8il sale of property or bu~iness, or relinquishment of employment
dt former domicile, removal of family to new domicJe, purchase of home, etc.)
Filing for Homestead purposes
113325
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1 FCr:TIIER CERTIFY that I wiIl registl'r at my local address when the registrntion books reopf:n, and comply
\\':ti, all ,thl'r YNluirements of a legal resident of this State.
I FUHTHER CERTifo'Y that I have no int'.!ntion to return to my former domicile, and I intend to remain in
FOHT I'II:HO:. SAINT LUCIE COUNTY, FLORIDA, permanently.
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"\(,~:~...,::;:~,:.>~..~\,;l)'~ w"l ,uhmibcd bdm' me this
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CLER1: rIR"UlT COURT
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By~6,.,!l.~ U<
IJ.~/; rJoJ( rJ g, ,A..-L
(Name)
BERH.Ai-<D (j. ;';'..05
(Address)
20tL
day of r'EBi:{UARY
,19 63
Notary Pub!k
D.C.,
b.y CommisSion expires _
('1'" he ('xcrut~,j In dupllt'ate and original filed with CIl"rk CIrcuit Court, and dupt:cate with Tax Aase&8or)
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