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" Declaration ot Don~tcile and Citise~ship .
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~ TQ TH~ ~TATE /WD GOUNTY TAX ASSESSOR,
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ST. WCIE COUNTY. FIORiDA:
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~ Thi= is my declaratio~ of Oomicile and Gitlunihip 1n th~ Stat~ of Horida that 1 am filinp fhit day i~ ~ooordanw ~+~d
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` in oonformiiy with Chaptet 224, Ssction 2Z2.17, Florid~ Statutss.
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1 w~s formsrly a leqel ~ssident of - t_
(~ity) (S~a»)
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~nd 1 rasided at ~9 l~• ~1b~D~ A~~• . Hovwver 1 have than~sd my domidl~
(Straat and Number) ~
~ ~ 19th
; b a~d am and havs been a bo~s fids msident of the St~» of Florida sino~ day of
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11~d ~~0~ a
~ S~D*i. , 19_~, and I roside st -
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~ ~ORT MERC~, SAINT ltlClE COtINTY, RORIDA
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i and thi: statement is ro be taken as my decia~ation of citiunship, actual le9sl r~idenos and domidle in th~ Stat~ of Horid~.
' qnsert here any pertinent facts, such as sale of ptoperty or bu:lness, or reltnquishment of ~mploymsnt
; ~t former dorr+icile, rsmovai of family to new domkile, purchase of hom~, etc.)
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3 1~'II+I~ l~'08 AEiL38Td~D F'UNP03E8
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~ fII.ED AND RECOROED . - ~ '~~~~~~~~a° =
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1964 JAN 21 PM 12: I 2 ':;~r~~
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ROGER POITRAS. CIERK F~~- i.°~s;~rrts~~9
~ St. IUCIE COUNjT, FLORIO
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~ 1 FURTHER CERTIFY that 1 will register at my loal address whe~ ths ~istration books reopsn, and oomply with Iy~:~
i~ all othsr roquireme~ts of a le~al rosident of this State.
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~ ~ 1 fURTHER CERTIFY that 1 have no intention to retum to my former domkile, and 1 tntend to remain i~ FORT
~ PIERCE, SAINT WCIE COUNTY, FLORIDA, permsnently. _ ~
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:~~~•..t- ;r il JanwrT d4 °
~nd wbsuil~d b~for~ m~ this day of 19 . s
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~ 0 C. My Car+missioe~ ucpires
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