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Declaratio~ of Domicile and Citisenshlp
TO THE STATE AND COUNTY TAX ASSESSOR, 143250
Sl. lUC1E COUNTY, FLORIOA:
This is my declaration of Domicile and Citizenship in the State of Fiorida that 1 am fili~g this day in aceordants and
in co~fo?miy with Chapter 222, Section 4?2.17, Florida Statutes.
I was forme~ly a tegal resident of __~#,~g~,#- 1KiChigarl _
(City) (State)
and I resided at 10~31 LBbOt Ave. Howevef I have changed my domiti~e
(Street and Number)
to and am and have been a bona fide resident of the State of Florida s~nce 22nd day of
~ugust _ ,~9
65, and I reside at Rt 2 Box 163 Rivexside Harbor _
(Sireet and Number)
fORT ~IERCE, SAINT LUCIE COUNTY, RORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the Stab of Horida.
(Insert here any pertinent fads, such as sale of property or business, or relinquishment of employment
at former domicile, removal of family to ~ew domicile, purchase of home, etc.)
Applying for homestead
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INIL ANO~R~OOK
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- . . i : n = ~ '66 MAR 3 1W 9 ' q ~
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k : ~'i = ROGER P~17RHS. CLERK -
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I RJRTHER CERTIFY that I witl comply with al) other requirements of a(egal resident of thia State.
I FURTHER CERTIFY that I have no intention to return to my former domicile, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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C~,worn lq~a~nd subscribed before me this 3r,~ day of ~rcb , 19 66
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Roc;~rt rom~As
- CIRCUR COURT Notary Public
By D.C. My Commiuion expires
(To b~ ~x~cuttd in dupliut~ snd ori~inal ~il~d wilb Cl~rlc Grcuit Cou~t, snd duplieat~ wi~h Tax /bs~ssor.)
aooK139 474
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