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Deciaration of Domiciie and Citizenship ~~~t)33~ ~
TO THE STAI'E ANO COUNTY TAX ASSESSOR.
St . LUCIE COUNTY, FLORIDA:
This is my declaration of Domicile and Citizenship in the State of Florida that I am tiling this day in accordance and
in conformity with Chapter 222, Secticn 222.17, Fiorida Statutes.
I was formerly a legal resident of '~U~
- -(City) _ _ _ . (State)
and I resided at P• _Q~ ~ _ _ _ _ _ _ However I have changed my domic.iit
(S!reet and Number)
to and am and have been a bona fide resident of the State of Florida since ~ day of
Nov~,mber ~ q65 Totten a,d. C:an. Del.
_ _ , and 1 reside at
- - - - (~treet and Number) 4--- -
FORT PIERCE, SAINT Ll1CiE COUNTY, FLORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Florida.
(Insert here any pertinan! facts, such as sale of property o~ business, or relinquishment of employment
at former domicile, removal of family to new domicile, purthase of home, etc.)
EN'1'EFtING ONE (1) Q~iILD IN PUBLIC St~~OL
RUDC)Q.F ffi~AESIId (8 yxs)
f-'ILED ~NU ~?FCORD= C
„
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, . ~ 18 F,, ~ . ..2
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. ;'f• •~r,: - :.'i. Ll1Cit Ci,Ji~i'(,
FLO f~ l f~.~
I FURTHER CERTIFY that I will comply with all other requirements of a legal resident of this State.
I FURTHER CERTIFY that I have no intention to return to my rormer domi~ile, ~nd I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLOi21pA, permanently.
' ~ ~ , I ' C' ~ ~ i, - I~-~~ft.. G<-~. -E' L, ~
= . / (Name)
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~ " . . ~G-.'; - , ~2`S. ~,'i?e~1"ri ~~A~6I3
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~ • s~ ; ~ (Address)
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~ ' • ' 7C~7a18th ~tov~ber , t 9 65
--;:$yyRcn to and subscribed before me this day of
ItOGER PO S
CLERK CIR U COilR1 Notary Public
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By - D.C. My Commission expires
(To be ex~cutesl in duplicate :nd origina) filed with COerk Circuit Court, snd tiuplicats with Tax Assesaor.)
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