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Declaratlo~ ot Domicile and Citizena~hip ~
TO THE STATE AND C~UNTY TAX ASSESSOR,
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~ Sl . LUCIE COUN'TY, FLaRIDA: ~ ~ ' ' ~ ~
This is my deciaration of Dom~cile and Citizenship in the State of Florida that i am filing th~s day in accordente and
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~ in conformity with Chapter 222, Section 222.17, Florida Statutes.
I was formerly a legal resident af S~'Ze~ Indiana
fCiry) (Sfatt)
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; 105~ S Main ~ ~ ~
~ and 1 resided at _ - _ _ However I have changed my domi~ile )
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~ to and am and have been a bona fide resident of the State of Florida since 3_.____ day of ~
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' October 65 Shambock Yillage ~
~ - _ . _ , 19--- - and I reside at - - - - -
(Street and Number} #
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+ FORT PIERCE, SAINT tUC1E COUNTY, F10RIDA
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~ and this statement is *o be taken as my declaration of citizenship, actual legal residence and domicile in the State of Florida. ~
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~ (Insert here any pertinent facts, such as sale of property or business, or relinquishment of employment
~ at farmer domicile, removal of family to new domic~le, purchase of home, etc.}
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~ Fntering children in 2nd, 3rd, 4th 3~ 5th G~ades
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~ . - '65 C~!'1' 8 FM 3: t~ 0 -
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" •;•t~ ROGC_h F~.:.; ~ <<.~~, ~~ERK
} ~ ~ S7. LUCIE COUyTY
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~ I FURTHER CERTIFY tt~at I wilf comply with al! other requirements of a legal resident of this State.
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~ ! FURTNER CERTlFY that I have no inier,tion to return to my former domi~ile, and I intend to remain in FORT
' PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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' • • (Name)
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~ ` Doris N, Strasser
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~ Sworn to and subscribed before me this 8~__ day of ~ t~be T ~j ~ 9 b 5 i
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~ ROGEit POITRAS _ _ ~
~ CLERK CI IT COURT Notary Public ; ~
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! Y - - D.C. My Commission expires ~ !
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~ (To bs executed in duplicate and originai ~Isd with Clerk Circvit Co~rt, and duplicate witlr ~sx ~?s~+sssar.)
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