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Declaration ot Domlclle and Cittzanship ~ i
.~zss~ ~
~ TO TH~ STATE AND GOUNTY TAX ASSESSpR, ~
ST. tUCIE COUNTY, FlOR10A: I
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Thts Is my declaration of Domicils'and ptizsnihip in the Stats of Florida that 1 am fili~q this day i~ ~ooorda~a and
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f~ aonformi~y wtth Chapte? 22Z. Section 2?2.17. Fla~ids Stat~tes. I
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: 1 wa: formerly a Isqaf rosident of Medina Nefr YWC`~
(City) ~ab)
396 ~is Street
~~d 1 ~uided at Howev~r ! haw chsrpsd my domldl~
(St~eet and Number)
~o Md am and hsve been a bona fids rosident of the State of Fforida st~+os - 23 day of
~ ~~$t 19 6~ ~ Route 2 boa 2660
, and 1 rotWe at
(Sheet and Numbaf)
~ORT ll~fx, SAINT lUC1E COUNTY, RORIDA
s~d this sbtern~r~t is b bs tsken as my declaration of dnzsnship, actusl laps! re~tdenoe end domldl~ in ths Statr of Horida.
pn~t here any pertinent fach, :uch as sale of property or lx~:ine:s, or rolinqut~ment of employm~nt
at former domidte, ronwval of family to new dorr?idle, puahase of har~e, etc.)
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Eatabliehing reeidenae ~ . : Ep ~ i
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` ~ . ~ 1964 allG 3l PM 1: 36 ~ '
,
~ ~ ~ - ROGER POITRAS.L'IERK ~
t•~~'~ - St. IUCIE COUNjY. f 1OR10
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; 1 FURTNER CEltTIhY th~t t wtll aomply wlth all otF~u nqulrorr~snb of a Ipal resident of thb Stat~.
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1 fURTF(ER CERTIfY that 1 hav~s ~a intention to retam to my formsr domWls, and 1 i~tend b remstn in FORT
: PtERCE. SAINT LUCIE COUNTY, FLORIDA, permanently. '
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' f •~ii ~v~ ' • .
~ ' ~ ~ s~ . ~ RoberL I.ee Willis
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~ Auguet 6~
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ti~ts
and sub~bed befon ms thls ~ day of 19_.
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~K ~ ' Notary Publk
? dl? 0 C. My Corrwnissfon ~xpi~ .
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- tTi Iw ~ iN d~rpNuM a~ «iaMal At~d wiM~ d«Ic txna~t Cew~. asd dupfjaN ~oc As~ra
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