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De~i~ration o! Do~ni~:lte and Citlzenship
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?O THf STATE AND COUNTY YAX ASSESSOR.
51. LUCIE COUNTY, rIORIDA: .
This is my decla~atior~ of Wmicile and Citizensh~p in tl~e Stete of Plwida that 1 am filing this day in scootdanoe and
in conformiry with Chapte~ 222, Section 222.17, Florida Statutes.
I was formerly a laga! res~dent of ~brewsb~rv ~ Massachus~ts HASSACHUSETS
° (City) (State)
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and 1 resided at ___a5 SuirF~y Lane ~ . However 1 have chanqed my domic,ile
(Street and Number)
to and am and have been a bona fide resident of ihe Stste of Florida since NQVeml~r 7~..._ 196S dey of
Novemb2r , 19 66 a~ ~eside at 30~7 Treasure Island Road
(Street and Number)
~
fORT PIERCE, SAINT LUCIE COUNTY, RORIDA
and this statement is to be taker} as my declaratio~ of citizenship, actual legal residence and domidle in the State of Ho~ida.
pnser~ here any pe~tinent facts, such as sale of property or business, or relinquishment of employment
at former domicile. ~emoval of family b new domicile, purchase of home, etc.) ~
HOMESrEAD PURPOSES _
FILEO AND RECOROEO
ST. LUCiE COUNTY. FLA.
RECORD VERIFIED
lso~zo
'66 OEC I2 Aa1 I1:36
ROv"EK r"'OITR~.S
; CLERK CIRCUIT COURT ~
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1 FURTHER CERTIFY that I- will camply with all other requirementa of s{egal rasident of this State. _
v no intention to retum to m former domitile, and 1 intend to remain in FORT ~
1 FURTHER CERTIFY that I ha e Y ~
PIERCE, SAINT lUCIE ~OUNTY, FLORIDA, permanently. _
_ ~
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~ Ma""e~ HBRBERT E. BgRG !
r,~ 308? TREASURB ISLAND ROAD
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_ : • (Address)
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~ ' •f $wptrt,to'and~ z~rbsuibed before me this 12th day of December ~q 66 ,
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~''~~:ipF~IRtUIT CO T Notary Public
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gy p,C, - My Commission expires
(To b~ ~acuhd in dupliute and ori~insl ~I~d with Ckrk Circvit Courr, and dupliut~ wilh Tax Asassor.)
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