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~ Declaration of Domicile and Citizenship i~,~,!
TO THE STATE AND COUNTY TAX ASSESSOR,
51. LUCIE COUNI'Y, FIORIDA:
This is my declaration ot Domicile and Citizenship in the State of Florida that I am filing this day in accordance and
in conformiry with Chapter 222, Section 222.17, Florida Statutes.
I was formerly a legal resident of --B~I~tOn Ij~------
~~;ty~ (State)
and I resided at E04_ HiCkm~T1 _ St~~~~______.____ . However I have changed my domiSile
(Street and Number) , _
to and am and have been a t~ona fid~ resident of the 5tate of H~rida since LSt day of
Auau~t- iv
65_, and I reside a; --~~1- Bin~n Driv~ kiver Parr_----------
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(5treet and Number)
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the 5tate of Florida.
(Insert here any pertinent facts, such as sale af property ar business, or relinquishment ot employment
at former domicile, removal of family to new domicile, purchase of home, eYc.)
FILED AND RECORDED
Establishing residency
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ROGErZ f'U~~i;d,:~, CLcr^tK
ST. LUCl~ COUNTY. ~ 1:
FLORIDA .r.,•: ' •
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I FUR7HER CERTIF`! that I will cornply with all other req~irements of a legal resident of this State.
I FURTHER CERTIFY that I have no intention to return to my former domi4i~e, and I intend to remain in FORT
PtERC~~~ SAN'if,tUClE COUNTY, FLORIDA, permanertly.
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'';;r .:~ti-?~' - (Name)r~
' ; - ` • Bobb it Z.. Ho l~an
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Swom to and subscribed before me this 4t.~iay o~ ~~~s , 19____5~25
ltOGER POITRAS
K CiRCU1T COURT Notary Public
~ D.C. My Commission expires
(To be sxecuted in duplicate and original filed with Cleric Circuit Caurt, and dupliute with Tax Ass~ssor.)
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