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Oeclaratlon ot Domicil• and Cltizenship 159124 i
TO TNE STATE AND COUNTY TAX ASSESSOR,
;
Sl. IUCIE COUNTY, FLORIDA: _ ~
This is my declaration of Domicile and Citize~ship in the State of Florids that 1 am filirp this day in sooordanos and
in conformity with Chapte~ 222, Section 222.17, Florida Statutes. •
I was fo~merly a legal resident of Na~~le Tennes~ee
(Cty) - (St~t~)
and 1 ~esided at - 2u ~ntrell Avenue . Howevsr I have chanqed my domkile
(Street snd Numbe~)
to and am snd have been a bona fide resident of the State of Florida since ' ~ , day of
Aue~$t , 19
6Z, and 1 reside at ?6~ Prima Viata Youlevard
(Sheet and Number)
Port St. Zucie
FORT MERCE, SAINT LUCIE COUNTY, FLORIDA
and this statement is to be taken as my declaration of citizenship, adusl leyal residenos and domicile in the State of Horida.
(Inse~t he~e any pcrtinent facts, such as sale of property or busineu, or ~eliaquiahment of employment
r
at former domicile, removal of family to new domicile, purchase of home, etc.) ;
~ • ~ , , ~ y)~ A. ~ „u,~,~~~tl.Lu,~ ~.~i"l~'1 ~l'~/+~.(~ ~
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Q. , ~G~u~t,~ o `~G• ,csE.~..~.ci . ~~~~~~t
Cl~c;e~c.L x. at~• ~ ~
~ yf ~en n th Grad ~
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~ F1LE0 AND RECOROED :
~ ST. LUCIE COUNtY. FLA. !
_ RECORD VERIFIEO '~',~vy (
' 159124 .,~I? ° ~
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~ '6t AUG I S PN I: 41 :
~
~
~?Q'sE? ~ 017R:.S ~
CLERK CIRCU{T COURT ~
. . - ~
1 FURTHER CERTIFY that I will aomply with sil~ other requiremenfs of a lepal resident of this State.
1 FURTHER CERTIFY that I have no intention to retum to my former domicjle, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. ;
_ - ~~Gf,,~t ~ G~..P~.,~
(Name)
Mrs. Mary Qlen
~6 'f ~'.~GQ
.~a(i~-~ ~iur..t..~. '
(Address) ~ ~ ~ ~
i
•'5wori~t¢•w,~d subxribed befo~e me this -l~lh dey of ~ug!~°~ . 19~• ~
, . ~
`~-ROaER ~O_I'~RAS -
. ~'~K ~~.CpV~ ' Notary Public
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~
gy D.C. . My Commisiwn expires
~
••T~.~_
.
(To b~. ix~d i~ dupliut~ snd ori~inal Al+d wila CIKk Ckaif Caut, ~nd duptkat~ wbh Tax As»Ma.)
. - B1~0:( .L~ 7 FAGE~~~~
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