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Declaratian ot Dort~icite and Citizensh~p
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TO THE STATE AND COUNTY TA?( ASSES50R,
Sl. LUCIE COUNTY, FLORIDA
This is my declaration of Uor~'~~c~le anc! Cit~zenship in the State af Florida that I am filing this day in accordance and
~n conformity with Chapter 222, Sectior, 222.17, Florida Statutes.
I was farn-:erly a legal resicient of V~dOSt8 ~80Y`g~a
(C~ty) (5tate)
and ! ~esided at ~~t ~~ress pvenue Nowe~e~ I have changed my domi~ile
(Street and Number)
to and am and have been a bona fide resident of the State of Fiorida since 27~ day of
CCtObel^ , ~965 , and I reside at 201~ S~ 35th Street
_ -
~Street and Number)
fORZ' f~IERCE, SQItJT LUCIE COUNTY, FLORIDA
and this statement is ta be taken as rny deciaration of cit+zenship, actual legal residence and domicile in the State of Florida.
(Insert here any pe;;ir,ent facts, such as sale of praperty or business, or relinqu~shment of employmenr
at former domicile, removai of family to new domicile, purchase of hom~, etc.)
TO PLACE GgiII,D IN SCH~OL
F! 1_ F
Gl.enda Ann Proveaue 7 yrs. ~+F'~~~~ '~~~D~e
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I FURTHER CERTIFY that I will comply with all other requiremertts c~f a legal resident af ihis State.
I FURTHER CER7IFY that I have no inten!ion to resurn to my former domi4ile, and I ir,tend `o remain in FOR7
PIERCE, SAINT LUClF COUf~!TY, ~LORIDA, oermanently_
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(Name) P~Lil- P2`oVeaue
2a1~: S. 35th ~treet~ Ft, Pierce~ F1a.
(Address)
, • ,
Swom to and subscribed before me this _ 2~_____ day of __~~~~r 19~_.
ROGER POITRAS - -
CLERK C!R UIT COURT Notary Pubiic
~ - D.C. ~Jly Commission expires
By _ _ - - L - ~ - - ~
(T~ b~ ~xecuted in duplicate and original filed wi4h Clerk Circuit Court, and duplicate with Tax Assessor.)
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