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Declaration ot Domicile and Citize~ship
TO THE STATE AND COUNTY TAX ASSESSOR, 14382~
51. CUCIE COUNTY, FLORIUA:
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This is my declaration of Domicile and Citizenship in the State of Ftorida that 1 am filing this day in accordance and ~
~n confo~mity with Chapte~ 222, Section 222.17, Florida Statutes.
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1 was former(y a legal res~dent of _ Se_lam _ _ _ _ _ Tennesse~ _
(Ciry> (State)
Route 2
and I resided at _ . However 1 havechanged my domic,~le ~
(Street and Number) ~
ro and am and have been a bo~a fide resident of the State of Florida since 1St day of ~
December 65 ?12 Azalia Ave. ~
- - - 19---, and I reside at -
(Street and Numbe?) ,
T-ORT PlERCE, SAINT lUClE COUNTY, RORIDA
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and this stateme~t is to be taken as my declaration of citizenship, act~al legal residence and domicile in ihe State of Horida.
(insert here any pertinent facts, such as sale of property or business, or ?elinquishment of employment
at former domicile, removal of famiiy to new domicile, purchase of home, etc.) ~
_ _ _,k
Establishing residence and applying for homestead
~ROED ~
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• . . • ` . ~~~T_ 'LUC1E COJNTY.
~ • F~ORIDA
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I RJRTHER CERTIFY that I will comply witF~ al( other requirements of a legal resident of this State. '
I FURTHER CERTIFY that I have no intention to return to my former domic,ile, and I intend to remain in FORT
P(ERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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- - Billy God rey
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' ~ ~ , ? (Address)
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~ ~~c.~',.~ 24th March 66 ~
SwoRnitpaind subscribed before me this day of ,~q . ~
ROGER POITRAS
CIRCU ~OURT Notary Public
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By D.C. My Commission expires
(To b~ ~x~cut~d in duplicaM and oripinal filed with Clerk Grcuit Court, and dupliute wifh Tax Assessor.)
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