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Declsratio~ ot Domicile a~d Citiz~nship -
~ - 1515'73
TO THE STATE AND COUNTY TAX ASSESSOR,
~ 51. lUC1E COUNTY, FLORIDA:
~ This is my declarofion of Oomicile and Citi=enship in ths State of Florida that 1 am filing this day in acoordanw and
in oonformity with Chapter 222, Section 242.17, Florida Statutes. ~
North Carolina
1 was formerly a legal ~esider~t of NpulbusA
(City) (Stats) ~
and I resided at _ BOR 291B , Route 3 However 1 have chsnqed my domkile
(Street and Number)
to and am and have been a bons fide ~esident of the State of Florida sinoe 15 dsy of
, August , 19 06, a~ ~~ide at 114 Serenata Court
~ (Street and Number)
FORT MERCE, SAINT LtlCIE COUNTY, RORIOA - -
and this statement is to be taken as my declaration of citizenship, actusl legal residence and domidle in the State of Florida.
(fnsert here any pe~tinent facts, such as sale of properiy or busineu, ot relinquishme~t of employment ~
at former domicile, removal of family to new domicile, purthase of homs, etc.)
0 NB.ItE
, 8T.a
i1C~ COU
_ ECORD VERIFI~p
~stablishing residence ~l s ~ 8 ; ys
~~i5~'3
~ ~ ROGER POIfiRA3
Ct~RK CIRCUIT COURT
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i RJRTHER CERTIFY that i will oomply with all other requirements of a lepal resident of thls State.
I FURTHER CERTIFY that I have no intention to return to my former domicjle, and 1 intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FlORiOA, permanently.
.,...;,~,t (Name) ~
'~',.i~~~,~a~jfJ. . .
•1, , ..•h r.C l, r
-?~L• . k~, ~
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~,r~,~~, ~ - James William Potter
- : ~ : : ~ -
" :ti~:r,~.,•,^~r!~ ~-r:~ (Address)
- -s~:' ' ~:rJ
`•i• '.%~::..ti
£:~~~'-~-~jj;•~ ° . ~ 6th January 19 67
~ to~~qt~ =ubscribed before me this day of , •
t`~~' .
~ ~Y . .
''~fi. ~ i~~ .
~e4f~ltat>~t .
~ •~-c •
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CLk~K IRCUR COURT Notary Public
gy ~.C. My Commiu'wn expires ~
(Te b~ ~x~art~d fn duplica~ aed ori~insl fiNd wilb Ct~eic Ciraiit CaM, and duplicat~ wiN~ Tax A~ora
- Soo~ 164 ~ 13~
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