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Declaration of Domicile and Citizenship
. TO THE 5TATE ANO COUNTY TAX ASSESSOR,
.i384F3
51. LUCIE COUNTY, FLORIDA:
This is my declaration of Domicile and Citizenship in the State of Florida that I am filing this day in eccorda~ce and
in conformity with Chapter 222, 5ection 222.17, Florida Statutes.
Reedaville west Virginia
I was formerly a legal resident of
~C~ty~ (State)
and I resided at _ Rt_ 1 BOX__,122 . However 1 have changed my domiCile
(5treet and Number)
to and am and have been a bona fide resident of The State of Florida since _ 3I*t__ day df
Aiagvst ~K 80~ D leware AYe.
- - - T9'_.--, and I reside at -
{Street and Number)
FORT PiERCE, SAiN? LUCIE COUNTY, FLORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Flo~ida.
(Insert here any pertinent facts, such as sale of property or business, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etcJ
finterinA cha.ldren in school
No ~ECaRO~o
, F I L Ej.~.~-R~B~~ 0 0 K
. " Vj ~
~ . ~ . . : 5 p
~i . , _ . '65 SEP 1 9
~.38~~
' . . ROG;_;~ , ~~_,l ~ ,-r~`>u ~TYRK
" , • ~Y. LUCIE CO
- , : ~LORIDa
~~t:~ii~:t
! FURTHER CERTIFY that I will comply with all other requirements of a legai resident of this State.
I FURTHER CERTIFY that I have no inten!ion to return to my former domiCile, and 1 intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanenfily.
,,:;t::.
. - ~l// ,?v. ~-a,1.c~,,~ `~J
, ' ~,r~' r (Name)
- ~ ~ - Mrs James T Musgrave
.
~ . ; -
(Address)
. ~ • .
' . :
~ ' lst S~pteaber 6S
~~Sx?prn`to•,end~subscribed before me this day of 19 .
ttOGER POITRAS
K CIRCUtT COURT Notary Public
_ ~~'~`'t~ D.C. My Commission expires
(Ta ba axecuted in duplicate and original ~rlsd witb tterk Circuit Cuur1, and dupiicet~ with Tax 14ssassor.)
6~RK 1~~ ~ss
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