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Declaratlo~ ot Domicile and Citizenship 1524Q1 ~
TO THE STATE AND COUNTY TAX ASSESSOR,
51. LUCIE COUNTY, FLORIDA:
This ia my declaration of Oomiciie and Citizenship in fhe State of Florida that 1 am filir~ this day in aooadanos and
in conformity with Chapte~ 222, Saction 222.17, Florida Statutes.
I was fo~merly a legal resident of Sioux Falls South Dakota
(City) (Sta»)
and 1 resided at 329 North Prarie Avenue . However ~ ha~e chanyed my domidle
(Straet and Number)
to and am and have been a bona fide ~esider~t of the State of Fiorida since ~une 13.T-19b~. day of
_ une: , ~q 66 , and I reside at I~7 SW Placita Court "
(Street and Number)
FORT PlERCE, SAINT LUCIE COUNTY, RORIDA
and this statement is to be taken as my declaration of citizenship, actual legal re:idente and domicile in the State of Horida.
(insert here any perti~ent facts, such as sale of property or busineu, or relinquishment of employment
at fo~me~ domicile, removal of #amily to new domicile, purchase of home, etc.)
HOMESTEAD PURPOSES _
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1 FURTHER ~ERTIFY that I will aomply with atl other requirements of a leyal resident of this Stab.
1 FURTHER CERTIFY that 1 have no intention to retum y former domicjle, and I intend to remain in FORT
~
PIERC~,:SAM1T l.UGIE COUNTY, FLORIDA, permaneni{y.
• . .
~`~;::Inrl:~;~ J. i
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` ~ t . James W. Ches ut Name
~ ~ S ~ : v = ~
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=~-"~v-.='j~~~SL1~ti = 107 SW Placita Court
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~ (Address)
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'`''9~vorn•to and subscribed before me this Ist day of Febuary ~q~_,
.
ROGHt PORRAS
ClERK CIRCUII' COURT . Notary Public
.
BY --~''~v D.C. My Commission expires
(To b~ ~x~cut~d in duplieah and ori~inal Rl~d wHh Cl~elc Circuit Cou~, and dup11ca1~ wiTh Tax As~aor.)
~~Ki64 ~13~
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