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Declaration ot Domicile and Citize~ship
TO THE STATE AND COUNTY TAX ASSESSOR,
Sl. lUC1E COUNTY, FIORIUA:
This is my declaration of ~omicile and Citi=enship in the State of Florida that I am filing this day in accordance and
in conformity with Chapter 2~2, Section 222.17, Florida Statutes.
Ro ersville Tennessee
I was formerly a legal resident of _ _ ~ _ _ . _ . _ _ -
~C;ty~ (State)
609 DOUglas Drive _ However 1 have ~han ed m domiCile
and 1 resided at _ _ _ _ _ _ _ - 9 Y
(Street and Number)
to and am and have been a bona fide resident of the State of Florida since _ _z? day of
October ~9__ _ 65and I reside at _____1914 Royal Palm Drive
- -
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Florida.
(Inserl here any pertinent facts, such as sale of property or business, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.) '
FIL ~ R
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OK
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Establishing residence ~ ~~'~~~~f~U
Ra~c;; -
, ST- LUCiL COU JTYRK
~ F~ORID,4
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I FURTHER CERTIFY that I will comply with all other requirements of a legal resident of this ~S~b'~•:
I FURTHER CERTIFY that I have no iniention to return to my former domicjle, and I intend to r ain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
~ . (Name)
,~r
. .
~ - ` • bis~~cd Claude L. Lollar r. ?
~ ~ t ~~~y,' , :i, . ~ .l
~ _ • . v . 1 (AC~df@S5~
~ .~e: _ ' . ;
~ •''f - 29 _ ~larch 19 66
- Swqtri •to. art~ su~sriibed before me this day of ,
C':;:._ ' ti~
~ . . . . ~
~ ROGER POITRAS
~ LERK CIRC COURT Notary Public
gy D.C. My Commission expires
~ (To be executed in duplicate and originsl filed with Clerk G~cuit Court, and dupliuts with Tax Assas~r.) ~
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