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Deciaration o! Domlcile and Citlse~shlp
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TO THE STATE AND GOUNTY TAX ASSE~SSOR, ~46
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sT, w~ie couNnr, FIORI~a:
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This i: my decla~atio~ of Domicile and Citizenship in ths State of Florida that i am fili~q this day in acoordsr~oe a~d
in oonfamity with Chapter 242. Sectio~ 22Z.17. Florida Shtutes.
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1 was formerly a lagal resident of 1~'es''C Lwde d~l~ _ __,~1~sda ~
_ (City) (State)
~nd 1 rosided et 1~.*~ 16th Cot~Pl',
Howwer 1 have changed my domidle h=
(Streef and Number)
to snd am and have baen s bona fide resident of the State of Florids sinos dey of
~r~ , 19 40 and 1 reside at d901 3. Ind ia a Bi Tp1•~1•~,T,~
(Sneet and Number)
FORT rtERC~, SAINT tUCiE COUNTY, RORIDA - ~
• and this statement is to be taken as my declaration of citizenship, achial legal residenos end domicile in ths State of Horida.
(In~rt here any pe~tinent facts, such as sale of ptopery or business, or ~elinqulshment of emplayment
at fw~mer domicile, removal of family ro new domicile, purchase of home, etc.) ,.-y:
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t~ FlLED A~i ECOt' ED _
Eata ---Q~ ~ ~CCQ~
bliahi~g reaiden~~ ~--~_9QOK
, 1964 JuN 20 AM 11: 24
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c;4;;,.~-:• SROGER POITRAS. CLfRK
_ `~A . „ . LUCIE COUNTY. FLORIDA -
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~ I FURTH~R C'ERTIFY thst 1 will r connp~y with
alt other requirements of a legal resident of this Stale.
' 1 FURTHER CERTIFY that I have no intenY~on b mtum to my former domicjle, and I intend to remain in FORT
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PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. ~
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'.:~:~"'~v~ii~~cid~ivbacribed bsfore ~n. fhis L~ day of JaIIdllt'~ 19 ~
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Roac~e rom~ws -
CtR COURT Notary Publk
8Y D.C. My Commission sxpi?es
Ro b~ uacvbd 1~ duplkah i~d eri~Mal Bl~d w11i~ Cl~ric qrarM Coue~, and d~rpticah wHh ~T~ ~ r~,
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