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Declaration of Domicile and Citizenship , j
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TU TNE STAiE AND COUNTY if'~X A~:~ESSOR,
Sl. LUCIE COUNTY, FLO~tiDA
This ~s rr~y declaration of Dor,i;c~le and Cit~zensh,p ~n the State of F!orida that 1 am filiny this day in accordance and
i~ conformity with C.hapter 222 Section 222.17, Florida Statutes
I~Nas fornierly a legai resident of ~aS~ Wnrcester .New_ yQ~k _
{City) (State)
and I resided at E~St Wo~cester, NeW York Nowever I have changed my dorni~ile
(Street and Numb2r)
to and am and have been a bona fide resident of the State of Florida since ~~5th _ day of
1`Iovember , t9 ~5 , and I,es~de ar 2205 Florida__Avenu~_~
(Street and Number)
FORT PI~RCE, SAfNT LUCIE GOUN7Y, FIORlDA
and this statement is to be taken as my declaration of citizenship, ac.tual fega! res~dence and domicile +n the State of Florida.
(Insert here any pertinent facts, such as sale o# property or business, er relinquishment of employment
at former domicile, remaval ef family to new domicile, pur~hase of home, etc.)
I have moved to 5t. Lucie County, Florida, for the sole purpose
of establishing this as rny home and residence and having employ-
ment here, relinquishing all farmer employment at the former
domicile.
FILED AND RECQR~ED
: '",~t3Yd-._.g 0 0 K
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5 DEC 7 P~1 2:~~
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' - ROG~=i; i ; CLERK •
= 57. L'UC~E COUP~7Y.
• : FLORIDA
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I FURTHEf? CERTlFY thai I will compiy with all other requirements of a legal resident of this State.
I FURTHER CER7IFY that I have no intention to retum to my fcrmer domi~ile, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permaneni!y.
1 ~l r' ,~_y ~
(Name)
22~5 Flarida Avenue, Fort Pierce,Fla.
(Address)
Sworn te and subscr~i~ed before m~ this _ day of _ ._L~I4Y@1~E;~_- 14~~-•
ROGER P017RA5 - - - '""L - l
CLERid GIRCUi7 COURT Notary Public , StatE of F'1~, •at
~ Large
gy _ D.C. ~^Ay Commiss+on expires _ 2...-~~
i
(To be executeci i~ ~iuplicate and origina) fiisd ~ith Clerk Circuit Court, and duplicate with Tax Assassor.)
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