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~ Deciaration ot Domicile and Citisenship i}
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' TO TH~ ~TATi AND COI~NTY TAX ASSE3SOR~ ;i,~~
: Sl, IUGiE CQUNTY. FIORIDA: ` ~
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~ This is my decla~atio~ of Oomicile a~d Citisensh~p _ . . . . ~ , . . '+~i+ •.1~; irt ~tiarcianrc .~rtg :
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" in oonformity with Chapter 222, Ssction 222.17, Florida Statut~s. '
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3~. Lonis Yis~ouri ; :
` 1 was formerly a leyal re~dsnt of - !
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' and 1 nsided at 16 Y~0 CauslaYLd . Howwer 1 haw chanqed my domkll~
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b and am and have been a bo~a fide resident of the State of Florida since 5 day of .
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. ngnOt , 19 and 1 ~eside at 1~~ in~ A* - :f
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fORT MERCE, SAINT LUCIE C4UNTY, FLORIDA
and this stateme~t is to be taken as my declarstion of citize~ship, actva! leqal residenos and domicile in fhs Stats of Horida.
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(Insert here any peninent fads, sucfi es sale of properry or business, or reti~quishment of employmsnt
at forme~ domicile, removal of family to new domicile, purchase of home, etc.)
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Q~F~~~~DED '
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Ett~blishing residena~
' - 1964 JAi~ 23 AH I I: 2 I ;
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ROGER POITf~AS. CLEfiK,``'-~°!~09~~~~ ~a
. - ST. IUCIE COU~lTY. FIOR.~D~a~";~',. - '
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, I FURTHER CERTIFY thst I will register at my iocal address wfiere th~ reyi:tration books reopen, and aomply•with ~ t
all other roquirements of a legal resident of this State.
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1 RJRTHER CERTIFY that i have no intention b retum to my formar domkile, end I intend to remain in FORT : R
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PIERCE, SA1INT-RUC~E COUNTIf, FLORIDA, permanently.
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"`.,`°~;~:~worn ~.:nd.~siibiaib~d b.f~o~. nn. thh dsy o# - 19 .
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' CIR IT COURT Notary Publk i.
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sy D.c. N?y commissio~ expi~.s SE
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(Te b~ ~r M~Yca1~ ar ~~I NMd wilb U~rk Cirsvit Cow~, awd duptica~a wiM~ Tax A~~a
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