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DeCla~ation ot Domicile and Citisenship
TO THE STATE AND COUNTY TAX ASSESSOR. 1431~;~
Sl. lUC1E COUNTY, FLORIDA:
This is my declaration of Domicile and Citizenship in the State of Florida that I am filing this day in acoc~dance and
+n conformity with Chapter 222, Section 222.17, Ftorida Statutes.
1 was formerly a legal resident of ____._GS 111~O1~S ~h10~
(City) (State)
and 1 resided at _ 644 Sth Avetiu@ Fiowever 1 have changed my domicile
(Street and Number)
to and am a~d have been a bona fide resident of the State of Florida since 2S day of
Februa~}! , ~q_66 and I res~de ar 511 B S 31st Street ~
(Street and Number)
FORT PIERCE, SAINT LUCIE GOUNTY, RORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domitile in the State of Florida.
(Insert he~e any pertinent fads, such as sale of property or busin~ss, or relinquishment of employment
at forme~ domicile, removal of family to new domicile, purchase of home, etc.)
Bntering Dana Dawn Queen in 3rd Grade
F~ ~ E~~ OEO
~ ,N ~G;O~ 900K
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~ ~ + ' ` ' : - ROGER ~'0: + ~AS CL.ER
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~ . : . ST. LUCIE COUNTY.
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~ FLORIOA
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I RIRTHER CERTIFY that 1 will oomply with all other requirements of a(egal resident of this State.
1 FURTHER CERTIFY that I have no intention to return to my former domicjle, and I intend to remain in FORT
PIERCE, SAINT'IUCIE COUNTY, FLORIDA, permanently.
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Sworn to and subscribed before me this 1 day of ~rch ~ ~q 66
~
~ ROGER POITRAS
CLFRK CI UIT CO T Notary Public
,
By ' D.C. My Commission expires
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~ Ro b~ ~x~cuted in dupliut~ snd ori~inal fil~d with Cl~rlc Cinvit Cour~, and duplicst~ with Tax As~tsor.)
~ aooK 139 _ 391
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