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Declar~llon ot Dorr~icile and Gitizen~hip _1 ~3~1_f i~ ~
Tt7 'fHE STATE AND COUNTY TAX ASSESSOR,
Sl. IUCIE COUNTY, FIORI~A:
This is my declaration of Domicile and Citizenship in the State of Florida that I am filing this day in accordance and
in conformity with Chapter 222, Settion 222.17, Florida Statutes.
I was formerly a legal resident of , CO~ItgC s?tit~Otl Texis
(Ciry) (State)
3C2D Hensel Apartoents
end 1 resided at . However I have changed my domic.ile
(Street and Number)
to and am and have bee~ a bona fide resident of the State of Ftorida since _13 dey ot
_ 19-__ bsand I reside at ____.2707 16th Street
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(Street and Number)
FORT PIERCE, SAlNT LUCIE COUNTY, FLORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Fla~ida.
(Insert here any pertinent facts, such es sale of property or business, or relinquishment of employment
at former domicile, remova( of family to new cio~~nle, purehase of home, ett.)
B~tablishing residence ND REC• ~p
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'~5 AUG 19 •
13~~~~, I I . 01
ROG{~Ir N~,J~: j~r1~. CL.ERK ~
ST. LUCIE COUNTY, ~
~'LORIDA .,~•~~.a~; _
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I FiJRTNER CERtI~Y that 1 wi(( comply witfi af! ofher requirements af a legal resident of this Sf~td~: ~
I FURTHER CERTlFY that I have no intention to return to my former domi~ile, and I intend to remain in F~RT
PIERCE, SAINT iuCIE CCUNTY, F10RIDA, permanently.
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~ ~ . . . (Name)
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_ Williae~ A~ Sigurdson
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"~s.wCr~l'~~end subscribed before me this 1~ day of ~~St , 19_ ~5
ROGER POiTRAS . - - .
CtEItK CIR IT COURt Notary Public ~
By ~`_L~ _ D.C. My Commission expires
(Ta bs ~xecuted in dupticate snd oMgina! filed with Cle~k Circuit Court, snd duplicat~ with Tsx As~essor.)
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BoaK 125 . `~D
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