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DeelurdiGll of Doaaici1e and CitDenebip
TO TilE STATE AND COUNTY TAX ASSESSOR,
O.R:
8Q:~
Sl'. LUCIE COUNTY, FLORJOA:
57 fA'E50f
ST.IUClf C2UNTY. ru.'
the State of Florida that 1 am mini thill day in
accordance
This is my declaration, of Domicile and Cltbenahlp In
and in conformity witb Chapler 222, Section 222,17, Flo'ida Statutes,
I was formerly a legal resident of
Naghua
New Hampshire
State
(City)
46 ,West 'Hollis Street
(Stree: and ~umber)
to an,1 nm and have been a bona fide rellident of the Slate of Florida since
1\11'1 I "'e~ided at
However, I have changed my domicile
1st
day of
NIUll-u
(;Y'
19~ and I rellide.t 117 Wa Prima Vista Blvd
{Steet and Number)
June
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA,
{I'll! this !>ta.ement is to be taken as my declaration of citi&enship, actuRl legal rellidence and domicile in the State of Florida.
(Insert here any pertinent facts, SlI:h all sale of property or bwinelll, or relinquillhmeT!t of employment
at former domicile, removal of family to new domicle, purchBlle of home, etc,)
Applying for homestead
1013460
IN ~8mcf:(D~EfO.UDED
----.~BDOK
1963 rEa 2S ~H 1/: 0
Rf'l(\ 6
, vvER POITR .
Sf. LUCIE COU~TrAS. CL~r,K l~
· . FLORIDA, ,?
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I FURTHEf< CERTIFY that I will reglllter at my loeal address when the rea-illtration books re{)pen, ana comply
with ;.11 dher requirements of a lei'sl resident of this State,
I FURTHER CER'f'IFY that I have no intention to return to my former domicile, and I intend to remain in
FORT PIERCf~. SAINT LUCIE COUNTY, FLORIDA, ~rmanentl)'.
Bussiere
(Addre3ll )
~'.\ orn to an,l ~ub5cribed before me this 25
d~y of Fe brua ry
,19 63
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(T" be exe-clikd in duplicate and OMrinal filed with CIft'k (Ilr~utt eclrt, and dupUute with Tn Auesaor)
ROGER POITRAS
:~'F.RK CIRCUIT COURT
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