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Declaration ot Domiclle ~nd Cittse~ship
TO THE STATE AND COUNTY TAX ASSESSOR,
51. LUCIE COUNTY, FLORI~A:
This is my declaratio~ of Qornicil@ and Citizenship in the State of Flo?ida that I am fili~ this day in aocordanoe and
;n conformity with Chapte~ 222, Section 222.17, Ftorida Statutes.
I was formerly a iegal ~es~de~t of __Caruthersville________ _ Missouri
(City) {S1ate)
20?. West lOth , However 1 have cha eci m domitile
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 .___12th _ _ day of
- May 1966 , and I reside at Sn7 araen; ~ AyE+ -
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
and this statement is to be taken as my declaratio~ of citizenship, actual legal residence and domicile in the State of Ho~ida.
(Insert here any pertinent facts, such as sal~ of property or business, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
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FILED AND RCCORDED j
ST. l.UC1E COUN?Y. FLA.
Establishing residence RECOP.D VERIFIED ~
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'66 DEC 2 PM l2:30
150~30
RO~~R f'Of7R:,S
CLERK CIRCUIT COURT
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1 RIRTHER CERTIFY ihat I will comRly with all other requiremenis of a(egal resident of this State. ~
I FURTHER CERTIFY that I have no intention to return to my former domic,ile, and I intend to remain in FORT ~
PIERCE, SAITlT LUCIE COUNTY, FLORIDA, permanently. " ;
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.,t::r.u:;:;ra, " ' ~ - t
~.~.~t- _'f~;,;,=: {
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'v"' ~=;~~'%r~.~f~ Charl . Rushing ~
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~w~fJto and suburibed before me this 2nd day ot ecember . ,
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ROGER POITRAS ~
K CIRCUIT C URT _ Notary Public
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gy D.C. My Commission expires
(To bs sxecuted in dupliuro snd original filed ~rith Clerk Grcuit Court, and duplicate with Tsx Assessor.)
~ BOOK ~UQ PACE 25YC
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