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Decla~ation ot ~omlcil• and Citisanship 161`7'~0~ }
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TO THE STATE AN~ COUNTY TAX ASSESSOR,
Sl . LUCIE COUN 1 Y, FIORIDA:
This is my datlaration of Domitile and Citizenship in the State of Florid~ that 1 am filirp this day in etoo~da~os and
~n oonformity with Chapter 222. Section 222.17. Fiorida Statutes.
1
! wa: formerly a legal resident of _ BIAdMFI$LD~ HILLS MiChigan
(Ciy) (Ste»)
3711 Thornbrier Way
a~d I resided at - _ 4~1 Howevar 1 heve chanqed my domitile
(St~e~t and Numbtr)
to and am and have been e bona fide resident of the State of Florida sinos 13t day af
_ Januarp ,~q
67 , and ~ reside a: 3017 Morningside Drive Port St. Lucie
(Street and Numbsr;
FoRr PIfRCE, SAINT LuC1E COUNTY, FtORIDA °
and this statement is to be taken as my declaration of citizenship, actusl leya) ~e:idence and domicile in the Stero of Horida. '
(Insert here any pe~tinent facts, such as sale of property or busineu, or mlinc~uishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.) ~
Establishi~g residence
FILEO AN~ RECOR~ED'
sT. LUCIE COUNTY. FLA. ~
RECORD VERIFIED ~
. 1617'04
'61 N011 I g PM : 2~6 ~
,
rO~~R POlTRaS
CLERK CIRCUIT COURT
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1 RIRTHER CHtTIFY that I will aomply with all other requirements of a Isys) res'idsnt of this State. i
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1 FURTHER CERTtFY ti~at I have no intention to return to my former domicjle, and I intend to remain in FORT ~
PIERCE~'~AINT .tt1QE,CQIINTY, FLORIDA, permanently. ~
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Sworn to and subsuibed befora me this 1Sth day of November ~~q 67 _ ~
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i
ROGER I~OITRAS
CIRCUR COURT Notary Pubtic
g D.C. My Commission expires
Y
(Te b~ ~x~cuhd M d~eah and ori~inal fll~d with Cl~ric Coue~, and dMpliab wifl~ Tan A~.) -
g~K ~.69 L~;~
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