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De~laration ot Domicile and Citlsenshlp
14433'7
TO THE STATE AND COUNTY TAX ASSESSOR,
Sl. LUCIE CQUNTY. FIORIDA: ,
This is my declaration of Domicile and Citixenship in the State of Florida that I am filing this day in aooo~dsnte a~d
~n conformity with Chapter 222, Section 222.17, Flo~ida Statutes.
~ I was formerly a legal resident of Travers City _ MichiRan
(Ciy) , (State)
and 1 ~esided at Howevar 1 have changed my domicjle
_ (Street and Number)
.
ro and am and have been a bona fide resident of the State of Florida since 15. ~ day of
O~ctober 65 Box 903, $cho Street
, 19 , and I reside at
. (Street and Number)
FORT ~IERCE, SAINT LUCIE COUNTY, RORIDA
a~d this statement is to be taken as my declaration of citizenship, actual legal residence and domiciie in ti~e btate of Fiorida.
(Insert he~e any peninent facis, such as sale of properry or business, or relinquishment of employment
at former domicile, removal of f~mily to ne~~ domicile, purchase of home, ett.) .
FILEO AND RECORDEB ~
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Bstablishing residence _ _ ~ ~ ~ ~ !Z-; 38 ~
144~57 ~
ROGER POITRAS: CLERK • N
ST. LUCiE COUNTY. ~
~ FLORIDA
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1 FURTHER CERTIFlf that I will oomply with al) other ~equirements of a Is~al resident of thls State.
1 FURTHER CERTIFY that I have no intention to retum to my former domiGle, and I intend to remain in FORT
PIERCE, SAl1~1~_LUCIE COUNTY, FLORIDA, permanently. _
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- ~ ~ ~ ~ C ~ • ~e M Gardner
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~ (Address)
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•~:1~",~•~~ 11 Apri2 ~q 66 .
Swor~1'tb.and subsuibed before me this day of - .
ROGER POITRAS
CLERK C CUR CO RT Notary Public
gy D.C. My Commiu'ron expires
~To b~ ~x~arhd in dupliu~ and ori~ieal fil~d whh Gl~elc Ci~aiif Coir~f, and ~plicatr wifh Tax AsWaor.~
aooK 143 26
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