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Declaration ot Domicile and Citisenship 148135
TO THE STATE ANO COUNTY TAX ASSESSOR, •
51. LUCIE ~OUNTY, FIORIDA:
This is my detla~ation of Domicile and Citizenship in the State of Florida that 1 am fiting this day in aocordancs and
in conformity with Chapter 222, Section 222.17, Florida Statutes.
I was formerly a legal resident of LindenhL_rst -1VP.~t Y~*'k
(City) (StaM)
?52 Shore /'walk
and I resided at However 1 have changed my domidle
(Street and Numbe~)
to and am and have been a bona fide resident of the State of Florida since 2? day of
August 66 2608 02iio Avenue
, 19 and I reside at
(Street and Number)
FORT PIERCE, SAINT lUC1E COUNTY, FLORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicila in the State of Horida.
(inse~t here any pertinent fads, such as sale of property or busi~ess, or relinquishment of employment
at forme~ domicile, removat of family to ~ew domicile, purchase of home, etc.)
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Entering John Charles Simmo~s in 9th Qrade ~
" ames Dale Simmo~s in 8th Grade ~ ~~m
" Glenn Davis Simmons in Sth Grade
" Debra Jean Simmons in 4th Grade ~ c ~<Qv
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I FURTHER CERTIFY that I will comply with all other requirementa of a legal resident of this State.
I FURTHER CERTIFY that I have no intention to return to my former domitile, and 1 intend to remain in FORT
PIERCE, SAINT WCt~:.~AUNTY, FLORIDA, permanently. •
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_ ~s ~.3~~~ ~t r _ Mrs. Jean Simmons
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Sv~rorn to and subscribed before me this 2 day of September , ~q~_.
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ROGER POITRAS : ~
K CIR IT COURT Notary Public
gy D.C. My ~ommission expires
(To bs ~x~cut~d in duplicate snd original filsd with Cl~rlc Grcuit Cour~, and duplicat~ with Tax As~essor.)
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