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Decla~ation ot Domicile and Citisenship
TO THE STATE ANO COUNTY TAX ASSESSOR.
Sl. LUCIE COUNTY, FtORIDA:
This is my declaration of ~omicile ar~d Ctti:enship in the State of Florida that 1 am filinq this day in acoordancs end
in oo~formity with Chapter 222, Section 222.17, ftorida Statutas.
I was formerly a legal rosident of ~ C~uden Kex Jea~aey
(City) (Sta»)
and 1 resided at ` 322'r BTaucton i~,Ik . Howeve~ i have chan~sd my do,~i~ile
(St~eet and Numberj
ro and am and hsve been a bona fide ~esident of the State of Flo~ida sinte day of
lugnat 67 26~ I.akeshare Blvd. ~
_ _ , 19 , and i r~ide at -
(Street and Number) _
FORT MERCE, SAINT LUCIE COUNTY, RORIDA
and this statement is to be taken as my declarafion of citizenship, ectual leyal ~~idence and domicile ln fhe State of Horida. ~
(lnsert here any pe~tinent facts, such as sale of property or busineu, or ~elinquiahment of employmsnt
at ~ormer domicile, removal of family to r?ew domicile, pur~is3e .of home,,~tc.)~
~V~
~tering c~ildren in pnblic sahools FlLEp ANO RECORO~D~ ,
ST. LUCIE COUMTY. F1.A,'
RECORD VERIFIEO
NOA~H i~?NS J~tiSSf~I (12 yrs) i
SANDR~ DIwIdS J~CK90N (10 yra ) ~T A~~ 2~ g 7 - j
~ /~3C~~ .
ii0 ;EF? +"~t~tTRA3
CLERK CIRCUIT COURT
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1 FURTHER CERTiFY that I will oomply wNh a!I other requireman~ of a lsQa) resident of this State. ~
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I FURTHER CERTIFY thst I have no intention to retum to my former domiGte, and t intend to remain in FORT ~
PIERCE, SA1NT LUCIE COUNTY, FLORIDA, permanently.
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,~.~~~uu~ijiif; - Do2'!s J. ~S Jackaon
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: ~ ~ y , 19 67 `
. c~ ' ~ subxribed before me this ~'at' da of .
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' cou~r F
, Notary Public ,
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gY D.C. My Gommiss'wn expi~es ~
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Ra b~ in dvplicat~ a~d o~i~inst fif~d with Cl~elc ~iraih Cooef, and ~plicaN wi11~ Tsx Aa~e~.) {
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