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laration ot Domicile ~nd Citizenshi ~
Dec P
T4 THE STATE AND COUNTY TAX ASSESSOR, s~
_ 51. lUC1E COUNTY, FIORIDA:
This is my declaration of Dnmicile and Citizenship in the State of Flarida that I am filing this day in accordance and
in conformity with Chapter 222, 5ection 222.17, ~lorida Statutes.
I was formerly a legal resident of . _ ~Q$Etfi'll~t _ _ _ _ _ _ - SQAA.~itl~-- -
(~;ry) (State)
815 DOU 1tSS Dx'~v~ _ However 1 have chan ed m domiCilc
and I resided at - - - 9 Y
(Street and Nurnber)
to and am and have been a bana fide resident of the State of Florida since _ 5_ day of
v__- Jul~ b5 605 Ohio A~renue
19_--- , and I reside at
(Street and Number)
PORT PtERCE, SAINT LUCIE COIJNTY, FLORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Florida.
(Insert here any p~ertinent facts, such as sale of property or business, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
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Bstabiishimg residence OK
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~e~ ing children in school •
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1 FURTHER CERTIFY that I will comply with all other requirements of a legal resicJent of this State.
I~URTHER CEr2TIFY that 1 ha•:e no irtention to return to my former domic,ile, and I intend to remain in FOR7
PfERCE, SAINT.LUCIE COUt~TY, FLORIDA, permanently. ,
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,a ~ George Ws Lon~ _ _ .
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~ S,y~.fo and subscribed before me this 4_____ day of _ August_______- 19-.~a..$-
ROG~R POITRAS - -
CLERK CI UIT COURT Notary Public
gy ~~C-~.~-~~~ - D.C. My Commission expi~es
(To bs exscuted in duplicate snd originsl filed with Clerk Circuit C8~0~~~~ pliute with Tax I?ssesior.)
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