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Decla~atio~ of Dornicile and Citizenship 14$Clfi`7
TO THE STATE AN~ GOUNTY TAX ASSESSOR, ,
Sl. IUCiE COUNTY, FLORIDA:
This is my declaration of Oomicile and Citizenship in the State of Florida that I am filing this day in aao~dance and
in conformity with Chapter 222, Section 222.17, Florida Stt+tutes.
North Little Rock Arkansas
1 was forme~ly a legal ~esident of -
~C;~y~ (State)
305 ShOrt St . However 1 have cha ed m domivle
and 1 resided at - - - - - - - ~9 Y
(St~eet and Numbe~)
to and am and have been a bona fide resident of the State of Florida since _ 2?tb- day of
August _ , 1966 and I reside at Rt 2 Box 32?- No Federal
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
and this statement is to be take~ as my declaration of citizenship, actuat legal residence and domicile in the State of Horida.
(Insert here any pertinent fatts, such as sale of propery or business, or ~elinquishment of employme~t
at former domicite, removal of family to new domicile, purchase of home, etc.)
Entering chsldren in school
aN~ R~~
Oa~~A.
S~L,'vc0 OD ~R~F~ED
R • y6
34~9.
, ,66 ~u~ 14~~6'7
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1 FURTHER CERTIFY that I will aomply with all other requirements of a lega) resident of this State.
I FURTHER CERTIFY that I have no intention to return to my former dor~iGle, and I intend to remain in fORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
_ ~~.i:• - ~.~1 . ~..:%"i-
- ~`a~ • ` : (Name)
~r'• ~
~ ' ~t' : u _ Mrs Donald L. Hampton
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~ (Address)
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,~~``'"~i'~~"'~ 30th ~u~ust 66
bworn to and subscribed before me this day of , 19 .
ROGER POITRAS
CLERK CIRCUIT COURT Notary Public
B D.C. My Commission expires
s (To b~ executed in dvpliuro snd original filed with Cl~rlc Grcuit Couef, snd duplicat~ with Tax Ass~ssor.)
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