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~ d~claratlo~ at Domicile a~d Citiz~nshlp
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, TO THE STATE ANO COUNTY TAX A55ESSOQ, 1.3g~~~
= S'f . LUCIE COUNTY, FLORIDA:
This +s my declaration of Oomicile and Citizenship in the State of Florida that I am filingi this day in aetordance and ~
in conformity with Chapter 222, Section 222.17, Florida Stbtutes.
~ DBIAYAN
I was formerly a legal resident of -
r iCiry) (State)
and t resid~d at --_----_~1Q--$~~3h__~#.tt~t However I have changed my dom:Cile
(Street and Number)
y
b and am and have been a bona fide resident of the State of Florida since - day of
AtlgtiSt--~ --v 19-65 and I reside at 1 30 Del~utar~ Ave
^ (Street and Number)
FORT MERCE, SAiNT lUC1E COUNTY, RORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Flarida.
. (Insert here any pertinent facts, such as sa~e of property or business, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
.
TO PY.AlCB CHILIyREN IN SCHOCIL
Sasdra Sue Carsaa iZ years
Pitty Kay Car~raa 11 yeara ~ EC~
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S Al1G 2 0 AN~ 10 : 2~
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~ . .r~ ~ , = ROS~ R~ A01 rRA5• CLER~ ~
- ; UClE COUNTY,
. , : ; F~ORIdA
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I FURTHER CERI'IFY that I wilf comply with all other requirements of a legal resident of this State.
~ I FURTHER CERTtFY that I have no intentinn to return to my former domic,ile, and I intend to remain in FORT
PIERCE, SAlN7 LUCIE COUNTY, FLORIDA, permanently.
,
~ ~ (Name) lrtss. Basl aremsn , Jr~
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~ , ?s 1230 DelaMSr~ Ave., Ft. Pierce,~'la.
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~ : ' (Address)
~ . . r `~r~~"%,. y.
~ : 20th
: ~ ' ~ a ~
14*~.7[~[u _ day of ~ AU 1~tiSt _ 9.~~.
~1 ,,d ~ Sw~ 1m;a~ubscribed b~fore me this .
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~r~'i~~~~~ l~~ i URT P+fotary Public .
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; By _ ~ D.C. My Commission expires
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5 ~ 3S
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(Ta b+~ fx~cvhd in duplicaM ind r~ginal filar! wilh q~k Circv~i Court, and duplicah wiN+ Tax Amarsror.) ~
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