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Decl~ratlon ot Domtcil• and Citlzenship
14~1
TO TNE STATE AND COUNTY TAX ASSESSOR, ~
51. LUCIE ~OUNTY, FIORIDA: ~ ,
This is my declaration of [k~micile and Citi=enship i~ the Stste of Florida thst I am filing this day in aoo~dante and
in oonformity with Chapter 222, Section 22Z.17, Florida Statutes.
1~ras formeriy a legal ~esident of W~jtII~4b172~ Penn '
(City) (State)
and I resided at LOng_A~t 10 N Abore Street_ However~ have chanyed my domidle
(Street and Number)
to and am and have been a bona fide resident of the State of Florida since ~ 18th day of
August Temporary at
, t9 66 , and 1 reside at 115 So 17th street
• (Street snd Number)
FORT M~CE, SAINT LUCIE COUNTY, FLORIOA .
and this atatement is to be taken as my dedaration of citiunship, actual legai residence a~d domicile in the State of Horida.
(Insert here any pertinent fads, such as sale of property or busineu, or relinquishment of employme~t
at fo~mer domicile, removal of family to new domicile, purchase of home, etc.)
Bntering child in school ( Cathq Gump )
FILED ANO RECORDEO
8T. ~UCIE COUNTY. FLA.
RECORO VERIFIEO
..~~~~Ck~.Gl~~
'66 ~u~ 23 AM 9: 0 3
14~p1 ,
I ~:e:~c.r: -:~~~r~~s
~ CLERK ~1RCUIT CQURT
I
1 RIRTHER CERTIFY that 1 will oomply with all other requirements of a lega) 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 LUCIE COUNTIf, FLORIDA, permanently.
~~~~~?titltrt~jJ ~ ± ' •
=`~1VU~.~%C~U,Q~':- (Name)
:'~~4y~`~~~~; l~a; ~ , Frances I.. Pellegrin
. ' ~r
- . ,
~ rI p~1\ • ~
= '.s•: ~ .-:,Q_ (Address)
.
_ ~i - S . • ' . r.' ~ J
- ~~~1.•.;~ : .
_ ~
. .r~'~w .1~~``` . ~U lIS'~
l~~i~ri, ~~i?~il iubxribed before me this 23 rd day of ~ ~ ~q 66 .
,
` ROGER rO1TRA5
CIRCUIZ COURT Notary Public
gy ~ D.C. My Commission expires
(To b~ ~x~cut~d in duplicah and o~i~inal filsd witl~ Cl~lc Cirarit Courf, and duplicat~ wNh Tax Aa~s~or.)
S~i53 268
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