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Declaration ot Domicile and Citizenship 15~3~i4 ~ ;
TO THE STATE AND COUNTY TAX ASSESSOR,
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51. IUCIE COUNTY, FIORIDA
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Th~s ~s my declaration of Uomicile and Citizensh~p in the State of Florida tF.at 1 am filing this day in accordance and a
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~n conformity with Chapter 222, Section 222.17, Florida Statutes. ;
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I was formerly a legal resident of ~XE`~ H I~ - -
(City) (~tate)
64C9 Tucker Rd. S. E. ~iashington, D. C. ~
and 1 resided at . _ However I have changed my domic.ile
(Street and Numbe~) .
ro and am and have been a bona fide resident of the State of Florida since lSt _ day of
~ay 66 703 Gardenia ~ve.
- - - , 19-_ , and I reside at _ _ -
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, PLORIDA
and this statement is to be taken as my declaration of citizenship, actuaf legal residence and domicile in the State of Florida.
(Insert here any pertinent facts, such as sale of property or bvsiness, or relinquishment of employment
at forme~ domicile, removal of family to new domicile, purchase of home, etc.)
r ICII~G FCF< HORIESTEr1D PURPOSES
F~IED AND RECOROEp ~
ST. L~~~E COUNTY~ p~,q
R~CORD VERIFIED ~
'~s DEC 2 ~ f
PM 3 : Sy
' 151~~4
'~0'vER ~~OITR,t~S
CLERK CIRCUtT COURT
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s I FURTHER CERTIFY that I will comply with all other requirements of a legal resident of this ~tate.
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~ I FURTHER CERTIFY that I have no intention to return to my former domi~ile, and I intend to remain in FORT
" ~IERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
- - - - ~ 3 . -
i (Name)
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t ~ ~tART IN F . IVi;RSUN
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- - ~ r , - (Address)
- _ - - 29th December
- . Swom to and subscribed before me this _ day of ~ 19 66
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~ -a R~~' IT S , i
~ ` L~RK ~ItCU COURT Notary Public
~a gy L~ _ 6.C. My Commission expires -
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(To b~ sxecuted ' duplicate and originsl filed with Clerk Circuit Court, and duplicate with Tax Asssssor.)
= a~~ i63 P~~ 385
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