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De~claration ot Dorr~i~cile and Citizen$hip
s
~
TO THE STATE AND COUNTY TAX ASSE550R, ~
51. LUCIE COUNTY, FlOF21~A
this is rny declaration of Domicile and Citizenship in the Stare of Florida that I am filinn this day in accordance and
in conforrrity with Chapter 222, Section 222.17, Florida Statutes.
I was formerly a legal resident of Clifton Heights Penn.
(City) - - - ~State) - _
, and I resided at 2~g Ca~bri3g@RO~d _ However I have changed my domi4ile
(Street and Number)
to and am and have been a bona fide resident of the State of ~lorida since l~~t! day ot
- 8eptsmher .~~5 , and I reside ar 1~.4~ Easter Ave~
. (Street and Number)
FORT PIERCE, SAINT WCIE COUNTY, FIORIDA
and this statement is to be taken as rny declaration of citizenship, actuai legal residence and domicile in the State of F(orida.
(Insert here any pertinent facts, such as sale of property or business, or relinquishme~~t of employment
at forrner domicile, removal of family te new domicile, p~rchase of home, etc.)
Establishinr~ residency
~11~ . ~;ND ;E~~C~ ~ OOK
, . ~ _ .
~ o~~~ . c.~~-
. . . r PI'~ ! • ~ J ;
: ~ '~~J ~.~~~~~+i-)
. ~~LItK
~ a, , - ~'~;~:TY.
~ . L.~-1~;~ Gi~
. ~=~ORIDA
I FURTHER CERTIFY that i vvill comply with all other requirements of a legai resident af this State.
I FURTHER CERi1FY thafi I have no intention to return to my former domi4ile, an~ i intend to remain in FOR7
PIERCE, SAINT LUCIE COUNTY, FIORIDA, parmanentiy.
~-~C--~!~ti~.e'-'~`-~'_"~`__'
(Name)
~ ~Jack ~ri~call
, - . ~ _ _ . ;
(Address) ;
~ ~ ~ Carrie Dri~eoll ~
- . ~
; .~'Sw0'ra to en'd subscribed before me this _ 2_g~~ day of _~~C~IDb22` 19 65 ~
RO ER POfTRAS - - _ _
~ K CIRCtiiT C~QURT Notery Public
/G ~
t~_.L~ C .a~-r L
aY D.C. PJ'iy Commission expires
(To be executed in duplicate and ariginal filed with Clerk Circuit Ca~urt, and duplicate~ with Tax Assess~or.)
~o~K134 512