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- Decia~ration ot Dc~micile ~nd Citizanship
TO THE STATE AND COUNTY TAX ASSESSOR, ~~~5
51. LUCIE COUNTY, FLORIDA:
This is my declaration of Domicile and Citizenship in tt,e State of Florida that I am filing this day in accordance and
in conformity with Chapter ?22, Section 222.17, Florida Statutes.
; was formerly a legal resident of p~IN INDIANA
_ - - - -
t~;ty~ (State)
Rtl -MSIt1IISbUTg However I havechan ed m domiGile
and I resided at . _ . _ - - _ _ _ . . _ . . 9 Y
(Street and Number)
to an-! am and have been a bona fide residen; of the State of Florida since 2~tb _ day of
June 65 Shamrock Villa e
- - - _ 19- , and I reside at _ - - -
(Street and Number)
FORT PIERCE, SAINT LUGIE COUNTY, FLORIOA
and this stateinent is to be takan as my de~:~-arat~arr crf-r„~zenship, actual legal residence and domicile in the State of Florida.
(Insert here any pertinent facts, such as sale of property or business, or relinquishment of employment
at former domicile, rernoval of family to new domicile, purchase of home, etc.)
FlLED C~tJD REC Rb~D
EN'TERING ONE CHILD IN PUBLIC SCHOOL ' -1~~_RQCUt~_~ pOK
TERRY s. THOMPSON yrs) `55 SEP 2 Fi~i 3:~~ ~
1 u~J]
;t;:~r,tir;~ F~:.~G;_.` ~...ii._~r;iC
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- ~ , rLQRIGA
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( FURTHER CERTIFY that I wi{I comply with all other requirements of a legal resident of this State.
I FURTHER CERTIFY that I have no iniention to return to my former domi~ile, and I intend to remain in FOR7
PlERC~, SAINT LUCIE COUNTY, FLORIDA, permanently.
ame -
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s
~ _ I~~iRS . ,jERRY THOMPSON
(Address)
Swom to and subscribed before me this,,~+,~~nd day of Se~~'~
°~.i , 19-~--•
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i •'~(!,U$~~v~
ROGER TRAS ;
`c:-~.' ~J•r ~ -
CIERK RC IT COURT _ - > i~ Natary Public
- : ~ ~ ~
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gy _ _ .;,:1_:.~~.G~.f,. ` ~ ' ~ My Commission expires -
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(To bs oxecuttd in duplicata and c?rig7rt~e~_ wi~ ' cuit Gourt, duplicsts with Tax Af~~-~ !
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