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Oeclu~~tton ot Domicile and Cltizenship ~ 128519 '
TO THF STATE AND COUNTY 1AX A~SSESSOR, ' _ '
ST. WCIE COUNTY, FLORI~l1:
This is my declaratlon of Domidls and GitisMShip in the State af Ho~ida th~t 1 am filtn~ thh day in ~ooordana ~nd ~
in aonformiry with Chspter 22Z, Section 222.17, Florida Statutss. +
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I wu formeriy a legal resident of N~tehyille~_ - .
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~ and ~ ~ded a~ ~13 Acklen~ D~rive ~ ~w ~
(Streat and Number) _
b~nd am ~nd haw been a bona fid~ ~kknt of the Stats of Florida slna 28th dsy of
~ '~e ~9 6~, and ~ rsstds r 36~ Barrolough .
; . . {Street •nd Numbsr)
l~ORT N~, SJUNT WCIE COUNTY, RORIDA '
and this :tatement is ro be taken as my dedarafbn of dhzenship, actual lepal reiidenos and domidi~ In ths Stste of Horida.
, qnssn hsro any peni~snt fscts, wd~ a: ~le of propsrty or bv:insu, ~ relinquE3hm~nt of unptoyn~nt
~ • at fo~msr domidle, rsnwval of family to nsw domkile, purchese ot hane, etc.) -
~ Ehtering Virgil l~~rtin Lample~ in the let grade
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. 1 FURTHER C9tTIFY thd 1 will aomply with ali o4twr nqutrernsnts af a le~al raid~t o# thb Sts~. .
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1 fURTHER C~RTIFY thst t hav~s rta inbntion to retum t~ m~r formar domWls, ind i intsnd to re~netn in FORT
r ~ PIEfiCE. SJ1iNT 1t1C1E ~OUNTY, FLORIDA, permanently. - .
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. : r~,;:, ~ (~~.~i , Mre Benny T Lemple~ " .
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.<< ~n w,nd subsatbed befor. m. thh day of A~st ~q 6~# ,
ROG~ ~OITRAt -
- CNtCtlR COURT ' Nbtary Publk
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' ~ ~ D.C. . My Canuni:tion expir+rs
lTi i» ~ iw d~ptkaN a~i ~i~iwai fi~d witb Cl~k ~a~f Cow~, snd d~ wbb Tax A~ra
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