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~ij~~ 59 fME687
Declaration of )~f~uffl1 rfj~en8hip
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11.1415
TO TIlE STATE AND COUNTY TAX ASSESSOR,
:iT. LUCIE COUNTY, FLORIDA:
This is my declaration of Domicile and Citlzeruhip in the Slate of Florida that I
and in conformity with Chapter 222. Section 222.17, Florida Statutes.
i.fIl"J'l~
am filing this day in accoroance
I wu formerly a legal resident of
Charleston
[City]
s.c.
State
and I resided at
16i Rutledge Ave.
[Street and Number)
However. I have changed my domicile
to and am and have been a bona fide resident of the State of Florida lince _--.l~
58 190 Bonita
19_-. and I rei ide at
day of
April
Court
[Street and Nlolmber)
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA,
and thil statement is to be taken as my declaration of citizensh ip. actual legal residence and domicile in the State o'~orida.
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t\,..1rU'I,
[Insert here any pertine:1t facts. s~ch as s'lle of p~ o~erty or bu~iness. or relinqti'ishment of e~!111) ,
at former domicile removal of family to new doml':lle purchase of home. etc.] ,,{-~'-t:.O:',....., 1/ ~
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Homestead exemption purposes .:: t ..c;,~l".' ..,- : a ..
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114415
III FlLEp ..M'!D nECCR.DED
II. OHlclal Re_c~__ :-JOCK
1903 ~Pll -I Art 10: 41
('ROGER PCiI'l r\;.\~;. I}~~K
u T. LUCIE CeUI;~y. FLOill~~ ~J
{AY~.v
I FURTHER CERTIFY that I will register at my local address when the registration b~oks reope:l, and comply
with all other requirements of a legal resident of this state.
I FURTHER CERTIFY that I have no intentIOn to re turn to my former domicile, and I intend to rernsin in
FORT PIERCE, SAINT LUCIE COUNTY. FLORIDA, permanently.
/A ~.L.,"l/},~
[Name]
Sum.ne r
-.1.1/0. /1/1",
Harry A
[Address]
Sworn to and subscribed before me this
1st
__. 19.__..63
,April
4Y (11
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P..OGr:P. POITRAS ~......,~~~______ __ _ .
~ CLEP.\{ cm~t.: T COU!~T . ~..~~\.; ~.:~ :".0, Notary
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[To be ('_,('Cuted in duplicate and orlgln~l file.! trlth CJeJ'lc ~ ~uPt" and dupllC'ste
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Public
with Tax A.o;5essorl
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