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; Declaratto~ ot Domicile and Citisenship
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' TO THE STATE AND COUNTY TAX ASSESSOR, ' ~~~i3~j 4°"
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' Sl. Ll1CIE ~OUNTY, FIORiDA: ~
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! This i: my declaration of Domicils and Gitizenship in ths State of Horida that 1~m filtnq this day in ~ooord~nw and
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; in aonformity with Ghapter 222, Sattion 222.17, Florida Statutes.
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I was formerly a leqel resident of - .
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and 1 ~esidsd at 74:~ arseal~~t! Plaoe . l~owwer ! haw cha~psd my domld~~
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to and am and h~ve been a bona fide resldent of the Stst~ of Florida ~ sinoe d~y ~
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' ~pril 6S 414 S. ~r~n~a Port t. Lna id
' , 19 , and 1 resids et
(Sheet and Number)
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l~ORT r1ERCE, S/11NT LUCIE COUNTY, RORIDA
and this statement i: to be taken as my dedaratwn of citizenship, actual legal ~~tdenos and domkile in the Staro of Florida.
(Insert here any perti~mnt facts, sud? as sale of property or bu:iness, a roitnqulshment of employment
at famer domidle, removal of family to new domiale, purchase of twms, ett.)
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Establishing resid~ne~ 1.~~~ ~
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' ~~~=~v~~s;c~; 1964 ~l~l - ~ ~OK , _a
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i? I FURTHER CER'TIFY that 1 will ro~ister at my loul address when the reqistration books reopen, and oompiy wTth
! all other roquirements of s le~sl rosident of thi: Staro. ~
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~ 1 FURTHER CERTIFY that I have no intention to mtum to my former domkile, snd 1 intend to remain in FORT
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; PIERCE, SAINT WCIE COUNTY, FLORIDA, pe~manently. ~t::~
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, .~4: Sw~orti .to and wbscribsd bsfor~ nr thh day of •
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' CLERK R Notary Pubik
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