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Declaration ot Do~ntctt~ and. Citizenship ;
TO THE STATE M!D COUNTII TAX I~~SSESSOR, ' ;
s~. wne cou~,nr, FLORIDA: 132507
This is m~r declaration of Oomic~le a~d Citi~uhip In th~ Stat~ of Horida that 1~m f~linp this day in aooorda~a and
` i~ contormity with Ghapter 222, Sectlon ~?~.17. Ftorlda Sistutes. ~
I wai form~ly a Ie~aa1 rosident of Naycsoss ~ Geor~it
. (City) (Sfab)
~ and 1~tdsd at Rt 4 ' HowwK 1 haw d~np~d my domWl~
. (Streef ~nd Numbs~) ~
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b~nd am and haw bs~n a bona fids rosident of ths Statt of Fiorida iinos llth ~y ~
~
~ Jaauar~ ~ ~9 6 and i resids at 330 Miltoe Drfve ' ~
(Strest and Nuenb~r) ~
. 1'ORT ~IERCE, SAtNT LIlCIE COUWTY, ~LORIDA ' ~
and thJs sfafemsnt Is ro bs takan as my decla~ation of citi:enship. actual ~leqal residena ~nd domidl~ in th~ Stat~ of Horida.
(lnsKt her~ any pertins~t fsct:, wd~ as ~le of property or bust~es=, or nlir~quishn+~nt of ~mpbyrn~nt
' ~t former domkile, ~emoval of family b new dort~icile, purcha~ of ~w~r~e, etc.)
~ntering Blizabeth Ann in the 8th grade ~
. , Jerry `1'homaa Jr in tbe 5th
~ -1a3,'~,~sQ~ " Virgiaia Carol in the lst grade ~
- ~~~D AND RECOROED ~ ~
~~~c~B00K
1965 JplV f y AM 9: 43 ~ .
ROGER o~ a,._: .
POITRAS, CIERK ' •
ST. LUCIE COUNtr. FLORIDA ~ ` . . ~
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~ 1 FURTHER CHtTIFY that i will comply wtth dl oN~ nqulnm~rNs of a Ip~l ~td~M of thb~Stat~.
~ . - I FURTHER C.ERTIFY that 1 have no intention ro retum to my formsr domi~ils, s~d 1 inte~d to remsin in FOitT
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PIERCE, SAtNT LUCIE COUNTY, F~ORIDA, permanently, ~ .
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~ ~p •and subscrib~d bsfor~ m~ this 14th JaOUSS~? 19
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