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Declaration ot Domicile and Citisenship
13so~~
TO THE 5TATE AND COUNTY TAX A5SES5UR,
51. IUCIE COUiVI'Y, FLORIDA:
Y
rthis is my declaration of Domici~e and Citizenship i~ the State of Florida that I am fili~g this day in atcordance and
in confo~miry with Chapter 222, Section 222.17, Florida Statutes.
l~eredosia lllinois
I was formerly a legal resident of -
- - - - - - -
~~;ty~ (State)
- and I~es~ded at Gea ral Defivery . wowever I have changed my domi~le
(Street and Number)
to and arn and have been a bona fide resident of the State of Floride since 14 day of
August _ 65 S 33rd Street, ~ A.A.Green
, 19-----, and I reside at
(Street 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 State of ~larida.
(Insert here any pertinent facts, such as sale of property or business, or relinquishment of employment
at former domicile, remova~ of family to new domicile, purchase of home, etc.)
Bnttring children in Junior High S~hool snd Ble~entarq
, FI {ED AND RECQRO~p
- ~~~4~~-- ? 0 0 K
; :
I 6 :'-.:r' : ; 3
. _ . ~oc~;; ~ ,13SU~~
, ~ sT. LUCl~ C~U,1TY,
+ _ FLORIQj:
f~ _
' .
t FURTHER CERTIFY that ! will comply with all other requirements of a legal resident of this State.
I FURTHER CERTIFY that I have no intention to return to my former domi~ile, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUPdTY, FLORIDA, permanently.
- (Name)
• S -
~.1, Y i~ ~ ; Y
- ~ - Y: ~rs. H~rvey Green
~ • - ~ , (Address)
.a . , ~ , . .
" ~ 16 Au ust 65
. r; ~;'~.:.,.,r,+,wA~*o ~d subscribed before me this day of 9
• . ~l~ f ;~:i •
ROGER POITRAS - -
CLERK CIR 1T COURT Notary Public
C . .
dy L~ L_ EM-C._~.~_~ ~.C. My C~mmissi~n exr~r~s
(Ta be sxecutad in duplicste and arisina! filed with Clerk Circuit Court, and sluplicste with Tsx Asssssor.)
~~K i24 . 543