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Dectaration ot Domieile and Citlzenship
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TQ THE STATE AND COUNTY TAX ASSFSSOR, 1.a~C~~i~~
51. LUCIE COUNYY, FLORIDA:
This is my declaration of Domicile and Citizensh~p in the State of Florida that I am filing this day iri accordance and
in tanformify wilh Ch;pter 222, Settion 222.17', Florida Statutes.
I was formerly a lega! resicient of _ _UNIO~T CITY TBNN _
(C i ty) (State)
and 1 resided at _ 7C~7_ NO 4th_ However I have changed my domieile
(Street and Number)
to and am an~! have been a bona fide resident of the State of Florida since . I1th day of
---~At~$v-s#- - , 19____ 4~nd I reside at 19OZ __~lOilial Rd
(Street and Number)
FORT PI~RCE, SAiNT LtJC1E COUNTY, FLORtDA
and t~is statement is to be taken as my declaration of citizenship, actuat legal residence and domicile in the State of Florida.
(Insert here any pertinent facts, suth as sale of property or business, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
Staying at the Southernairt Motei until they a~ove on the 28th
uf August to the above address-
Entering Children in school
FILED AND REC~R~OdK ~ ' ~ -
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1.~~ ; ; .
r- _ . ~ i ~?~~S. CL~RK . . . .
ROGE,t r'~ _ • ~ _
ST. ~ FLORtDA r~TY.
I FURTHER CERTIFY that I will comply with all other requiremenrs of a legal resident of this State.
1 FURTHER CERTIFY that I have no intention to return to my former domi~ile, and I intend to remain in FORT
PiERCE, SAINT LUCiE COUNTY, FLC7RIDA, permanently.
. . . ~ ~ ( ` ~x.-.
_ ~ ~
. -
~ (Na e)
~ ~ ' Mrs. Sam ( Betty ) Carpenter
, . (Adr~ress)
.
~ Sworn to and subscribed befare me this __..~~bth_` day of ~ A_~uSt ~ 1965
ROGER POITitAS '
K CIRCUlT OURT Notary Public
J„~ ` ~4C~ ~~~`C.uLK.r
BY D.C. My Commission expires
(To bs sxecuted in dupticate and original filed wi Cle?k Circuit Court, sns~ duplicsfe with 1'ax Assassor.)
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