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Declaratton, ot Domicil• and Citis~nship ~
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TO THE STATE AND COUNTY TAX ASSESSOR, ~
ST. LUCIE COUNTY, FIORIDA:
This is my declaration of Oomicile a~d Citizenship in the Stats of Florida that 1 am filin~ this day in aoo~rdanoe and
in conformity with Ghapter 222, Section 222.17, Florida Statutes.
I was formerly a legal reaident of '
. - f - (City) • t51aro)
22j0 RQOSevelt ~vd.
and 1 residad at _ However 1 have charqed my domidie
~ - (Street and Number)
ro snd am ~and havs been a bona fide resident of the State of Florida sinoe ~a*' day of
, 19~ , a~d i restde at 2401 Olsander-
(Street and Number)
FORT M~CE, SAINT LUCIE COUNTY, FlOR1~A ;
and this atatement is to be taken as my declaration of citizensi~ip, actual legal residenoe and domicite in fhe State of Fiorida.
(Insert here any pertinent facts, such as sale of p~operry or business, or relinquishment of employment
at former domicile, removal of family to ~ew domidle, purchase of home, etc.) _ -
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FILII~ FOR A~BSTF.~AD P'U~06ffi
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- 1 FLRTHER CERTIFY that I will comply with all other requirements of s leysl resident of this State.
I FURTHER CERTIFY that I have no intention to retum to my former domiSite, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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~ (Name)
'~GU 13:;x ~'~i,y HHB$ S(~M~i1'8
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~ ~ ':;~'_'~iiGo~ ' ~ ~ ~bsuibed before me thia ~ day of J~ ~ , t 967 •
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CtFRK C C URT Notary Public
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gy D.C. My Commiss'ron expires
(To b~ ~c~arhd i plicah and ori~inal fil«! witl~ CIMk CirarH Co~r~, and dupliah wHh Tax At~or.)
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