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De~la~ation ot Domicile and Citi=enship ~5~41
TO THE STATE AND ~OUNTY TAX ASSESSOR, '
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Sl. LUCIE ~OUNTY, FlOR10A: ~
This is my declsration of Domicile and Citi=enship in ths State of Ftorida that I sm filin9 this day in aooordanos and
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in co~formity with Chspter 22~. Section 222.17, Florida Statutes.
1 was formerly a legal resident of OKR4QS I4I(~i
(~ity) ~ah)
and 1 ~esided at - ~~8n . However 1 have chan~ed my domiti~e
(Street and Number)
to and am and hsve bee~ a bona fide resident of the State of Florida since lst day of
8Y 316 Granadi
Y
M , 19?_, and I r~ide at
- (Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, RORIDA .r
and this statement is to be taken as my declarotion of citizenship, actual legal residence and domicile in the State of Florida. ;
(Insert here any pe~tinent fatts, such as sale of property er business, or relinquishme~t of employmsnt
at former domicile, removal of family to new domicile, purchase of home, etc.)
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• FILEO AND RECORDED ~
ST. LUCIE COUNTY. FLA. !
ENTERTNG QiII.D IN POBLIC SC~i00L ,.4 r~R~-, ,~=R!~iED
.i59441 ;
r. iarnII. xtrt~ c~r (~3 yrs ) '6~ A!'(' 2 S PM I: 5 S - t
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'til~'s~!' +'~.1~ j :j {
` CLERK CIRCUIT COURT
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I RJRTHER GERTIFY that I will aomply with all other requirements of a(epal resident of this State.
I FURTHER CERTIFY that 1 have no intention to return to my former domicile, and 1 intend to remain in FORT
PIERCE, SAIN'~ LUCIE. COUNTY, FLORIDA, permanently.
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: ~.~r 3: (Name) ~i
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' : --~i•'. ; ~1 = WIRFt~N O. G~Y
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5 - .~.I•~..t.t'::..i ~ 1
f:~. = _
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~ , _ 25 ~[ugust 67 ;
Swacn ~td ~and subsuibed before me this day of . 19 • ;
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ROGER POITRAS .
CLERK R COURT Notary Public ;
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gy D.C. My Commission expires
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(To b~ uc~cvt~d ia dupliut~ and ori~inal Al~d wilh C{~rlc Cirarit Coue~, and dupliutr wilb Tax A~.) ~
~~i~7 ~~797
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