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D~claratio~ ot ~omicil~ a~d Citis~nship -
TO THE STATE AND COUNTY TAX ASSESSOR, 159836
St. tIICIE COUNTIr, FLORIDA:
This is my detlaration of Domicile a~d Citizenship in the State of Florida that 1 am filin~ this day in aooordanos and
in oonfonnity with Chapter 222, Ssttion 222.17, florida Statutes.
. Paru Ohio ,
1 was formeriy a le~al resident of
(City) (Ste»)
a~d 1 msided at 810? Liberty Ave., ~~ve chanqsd my domkile
(Sheet and Number)
ro and am and-have been a bona fide resident of the Staro of Florida sinos lst ~y ~
Septeeber - , 19 67- , a~ ~ 613 B So i7th street
(Streef and Numbet)
FORT M~CE, SAINT lllClE COUNTY, IRORiDA
and this statement is to be taken as my dxla~ation of citi~enship, actual leqal re:idence and domfcile in the Sfat~ of florida.
~
pnssrt here any pertinent facts, such as ssle of property or business, w mlinquishm~nt of employ~rNnt ~
at former domicile, removai of family to rww domidle, purchass of hane, etc.)
Bntering Thoeas Lee Underti?ood in the Sth grade
,
~ f~LEp ANO RECORDEO . ~
gT: l.UC1E COUNTY. F~• ~
~~~e~;~ Ef21F1ED
6 PM 2 ' y~
'61 SEP 15J18~
t;avE~R i•O1TR ~URT
CIERK CIRCUIT C ~
I ~
~
1 FURTHER CERTIFY that 1 wiil oomply wlth all otF~sr requi~eme~ri of a lepai reside~t of tfiis State.
1 FURTHER CERTIFY that 1 have no intention to retum to my former domirjle, and I intend to remain in FORT
PIERCE, SAINT IUCIE COUNTY, FLORIDA, permanently.
Y
,..:~ui~r,},.y~' ~ .
J j•` .;,Cp Mrs James B
Underwood ( Roberta)
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' 6th Se tember , ~q 6?
;$i~ti~1`~¢~`end subsuibed before ms thi: day of 3? -
e: C~,~ 1:
RO~iER rO1TR/1t ~
ClRCWT COURT - Notary Public
gy cs.... Cv dc~l~-G~-~ D.C. My Comrr:ission expires
~Te b~ ac~arNd iA d~plieM~ and ai~i fil~d wilh CM~Ic CMarif Ceu~f, and dup~ wilh Tax A~ora
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B~ox168 P~ ~3~
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