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D~claration ot Domicil~ and Citiz~nship
TO THE STATE AND COUNTY TAX ASSESSOR. 161444
sT. wciE couNnr, F~~Ri~A:
This is my declaration of Oomic;le and Citizenship in ths Stats of Florid~ that I am filin~ this day in ~aoord~no~ and
in ao~forntify ~with Chepter Z22, Section 222.17, Florida Statut~s.
Cinninatti Ohio
1 was formerly a leqal resident of
(City) (Stat~)
end 1 resided at 6811 1~IoQStes P~Ye . However I hav~ chanqsd my domidi~
' (Stre~t and Number)
to and am and hsve been a bona fide resident of the Staro of Florida sinas 2Ld day of
M~rcti ~ , 19 67, and 1~ide at 101 S, B. Bsnyon Dsi~e
~ (Strest and Numbsr)
FORt rl~CE, SAINT LUCIE COUNTY, RORIOA
and this atatement is ro be taken as my declaration of citizenship, actual leqal residence a~d domidls in ths Stete of HoHda.
. E
(Insert here any pertinent facfs, such as sale of property or bu:iness, or relinqui~me~t of smployment - !
at former domicile, removal of family to new domicile, purchase of home, etc.) .
Bstabiiahing reaidence - ~
,
FtLED AND RECORDED i
• Sj. LUCIE COUNTY F' ~
, :~-rnz~ ~,cqlFlFplA.
a
161444
'67 NOV 3 PM i: 3I
~ : ~ ~
CLERK ~CIRCl11T COURT
~
t
1 FURTHER CERTIFY that I will oomply wlth all ott~ roquirerr~snh of a le~al residsnt of this Stafs.
. I FURTHER CERTIFY that 1 have no intention to retum to my former domidle, and I intend to remain in FORT
PiERCE, SAINT LUCIE COUNTY, FIORIDA, permanantly.
~~`ic:i?s~ rrril' - • ~a ~
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.~ti ~ ~ t ; 1 _ r~~t,y = v~
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~ ~;~~'v1ny~•b•4 v,,j ~Name1~l0 ti
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~J ;,:1_ ~•'~'~:`.~~~t Donald S~ O
~ ~~~;i:~ ~ ~ h :_`t~.~ .
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t~, : ~v . (Addreu)
t/n''•~~~:..::
~~,'~i,i`:: se:i
~''"SMi~n~to and wburibed betors me this 3rd day cf IdO~e~ber , 19 67
ROGEIt 'OITRIIS ~
C~~ ~p~ Notary Publk ~
:
gy D.C. My ~ommission eupiros
(Te b~ ~x~e~Nd M dvppcae~ a~ e~in~l fll~d wMb CM~Ic Cie+wit Cou~f, aod dvplkaN wilb Tax A~er.)
a~168 P~2893
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