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Deciaration of Dornicile a~d C~tizensh~p
- .L3~53:3
TO THE STA'fE AND COUNTY TAX ASSESSOR,
Sl. LUCIE CQUNTY, FLORIDA
This is my declaration of Dom~c~fe and Citizenship in the State of Florida that I am filing this day in accordance and
+n conformity with Chapter 722, Section 222.17, Florida 5tatutes
I was formerly a legal resident of Brtttle.baro Vernont
(City} (State)
RFD #~3
and ( resided at _ _ However I have ch~nged my domicjle
(Street and Number)
to ~nd am and have been a bona fide res;dent of the State of Florida since _ day of
~''~~?Y 65 5300 Ole aider Avenue
- - _ - _ , 19_ , and I reside at
-
(Street and ~lumber)
FORT PIERCE, SAINT LUCIE COUNTY, fLORIDA
and ihis sfatement is to be taken as my declaration of citizenship, actuat legal residenca and domicile in the State of Florida.
(Insert here any pertinent facts, such as sale of property or business, ar relinquishment of employment
at former domicile, removal of farnily to new domicile, purchase of home, :et~.)
Establishgin r~siden~e ~'ILED qNp R~CQ~ ~O
,
~ (?Ott
1:~.~i 's~ ~ ? ~ ~a ~ ~ : ~ ~
~ . Cr,~ . k0 uJ~`,~~
_ r S7~' ~~;,CfE~;,aS CL~~?K
~ COU,117Y,
. S ~ FLORfOs~
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I FURTHER CERTIFY that I will comply with all other requirements of a lega! resident of this State.
I FURTWER CERTIFY that I have no +r~tention to return ro my farrner domic,ile, and I intend to remain in FURT
PIERCE, SAW7 IUCIE COU~ITY, FLC?RIDA, permanently.
~
_ _ ~ _
` • {Name)
_ ~ ~
,4
~ ~ g ~ , D~via E. Clark~
E .
` (Address)
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~ ~~w8}+~~to~and subscr;bed before me this -__-----_14 day cf _-_------.-~~uIIe , 19 6~
~
' ROGER POITRAS
CLEitK CI UIT COURt Notary Public
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By __-~__--L_----__ [7.C. My Cammission expires `
a
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~ (To be executed in duplisate and originat filed with Cteric Circuit Covrt, and duplirato with Yax Asssssor.) ~
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