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Declaration ot Domicile and Citizenshlp
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13u i'+"":
TO TWE 5TATE AND COUNTY TAX ASSESSOR,
Sl. IUCIE COUNTY, FLC3i~1DA:
This is my declaration of Oomiule and Citizenship in the State of Florida that I am fil~ng this day in accordance and
in conformity with Chapter 222, Section 222.17, Florida 5tatutes.
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I was formtrly a lega) resident oF BaSt Hart~Ord COilqeCtiClit `
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(C;ty) (State)
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541 Burnside Avenue
and I resided at . However I have changed my domic,ile :~.~Y
(Street and Number)
to and am and have been a bona fide resident of the State of Florida since _ ~6 _ day of ~'s
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- June 65 6905 S. I~dian River Drive R> ~
- - , 19_ - - and I reside at - - - .
(Street and Number) ~ `Y`?='
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FORT PIERCE, SAINT WCIE COUNTY, FIORIDA 1`~ ~
and this statement is to be taken as my declaration of citizenship, actual legal resid?nce and domicile in the 5tate of Florida.
(Insert here any pertinent facts, such as sale of property or business, or reiinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
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Enteri~q dau hter in White Cit Ble~entar School I~~
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! FURTHER CERTIFY That I will comply with all otner rec,uiremsnts of a legal resident of this State. ~
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1 FURTHER CERTIFY that I have no intention to return to my ~armer domi~ile, and I intend to remain in ~ORT
PiERCE, SA1NT LUCIE COUNTY, FLORIDA, perrrzanently. ~
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~ ~ ; ~ ~ (Name) i
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~ ~ ~ Norma W. Walton ~
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y 1~' a 19 August 65 ; :g~ ~
• Sw~m to and subsuioed before me this day of 19 ~ i 4.'-'
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ROGER POitRAS i ~ : ~
CLERK C Ulv COURT 'Y Notary Public ~
g D.C. My Commission expires _
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(To ~io tx+ecutod in dupliata and orig+na) filed witit Cierk CirG~it Court, and duplicats wifh Tsx Ilssfsso~.) ~ .
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