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DeclaratiOl\.~~M~ r..~
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TO TIll-; STATl-; AND COUNTY 'i'^X ASSESSOR,
ST. LuCIE COUNTY, FLORIDA;
This is my 1l~laratlon I\f Domicile ~nd CiUzen.hlp In the State of Florida lhat I am filing this day In accordanc')
and in ~onformlty with Chapter 222, Section 222.17, Florida Statutes.
1 was forlllErly a legal resident of
Bath
New York
S ta t<l
(City}
an I I resided at
Rt U 4
. However, I have changed my domicile
(Street dud Number)
to. an.! Olll and hove been n b:ma fide resident of the State of Florida since
22nd
day 01
February
I!)
63 1102 Flu.Ave.
. and I reside at
(Steet and Number)
FOHT PIERCE. SAJNT LUCIE COUNTY, FLORIDA,
nllll this statement is to be taken as my declaration of dt.i.zen3hip, actual legal residence and domicile in the State of Florida,
.......
(Insert here any pertinent fach, such a8 sale of property or business, or relinquishment of employment
nt former domicile, removal cf family to new domicle, purchase of home, etc,)
Entering Christine Ann Bennett in the 5th grade
" June Mario Bennett in the 3bd grade
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I FURTHER CERTIFY that J will rerister at my 1~1 address when the registration books reopen, and comply
with all dher requirements of a legal r~sident of this State.
I FURTHER CERTIFY that I have no Intention to return to my former domicile, and I intend to remain in
FORT PIERf'F., SAINT LUCiE COUNTY,
FLORIDA, pe~~ .
. ~. ~<~"~A~
(Name) ~
Leroy ~oldsmith
(Addrpss)
SWfll'n ~o :.nll subscribed before me this
25th
Feba
53
da:; of _,_
, 19
. .-........
ROGER POITRAS
/!JERK CIRCUIT COURT
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.I "~otary Public
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(To be exe-cut...d In duplicate and orl,inal Wed whb
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: >>, ~mlll1l1ion l&pi'Kla
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Clerk Ck(~~.~tt, aDd dupUute with Tax .Aueuor)
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