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De~laration ot Dorr~iclle and Citlzenship
TO THE STATE AND COUNTY TAX ASSESSOR, 1-~~`j~'~~
51. LUCiE COUNTY, FLORIGo4:
This is my declaration of Domicile and Citizenship in the State of Florida that I am filing this dey in atmrdente and
in conformity with Chapter 222, Section 222.17, Florida Statutes.
BURI.ING~ON co r~w J~sBY
1 was formerly a Icga! resident of -
(City) (State)
and I resided at __8~~. 44 BIOMnS_ 1~I~lls _ However I have changed my domicjle
(Street and Number)
to and am and have been a bona fide res+dent of the State of Florida since _ Z1St_---.- ~ day of
------Stp~tl~?~.I----, 19~65, and I ~eside at 3602 A.dt R _
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, FLOItIDA
and this statement is to be taken as my declaration of citizenship, actual lega) residence and domicile in the State of Florida.
, (lnsert 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, etc.)
bntering childrtm in schaol
FlLED AND REC RDOOK
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. ~ '65 SEP 2q PMI 3:03
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' ROGER POITRAS, CLERK ~
- . ~ ~ ST. WCIE COUNTY,
. . . FLORIOA
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I FURTHE~R:CERTIFY that I wili comply with all other requirements of a legal resident of this State.
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t.~URTH~R C~RTl~FY ihat I have no intention to retum to my former domic,ile, and ! intend to remain in FORT
PlERC~, 5AlAtT LUCIE COUNTY, FLORIDA, permanently.
; . . , ~ . • A~lir y u ~i pp
. .~:r.,
~ . (Address)
24th Sep~
Sworn to and subscribed before me this - day of 19 6~ •
ROGER POITRAS -
CIRCUIT COURT Notary Public
U.C. My Commission expires -
(To be ~x~cutad in dup{icata and origi~al ~ilsd with Gler~lc Circuit Court, and duplica» with Tayc As~r.)
~~oK ~27 ~93 _
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