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~la~atio~ ot Domi~ii~ a~tl +~itisensttip 16~3i
TO THE STATE AND COUNTY TAX ASSESSOR,
51. LUCIE COUNTY, FlOR10A:
This is my declaration of Dpmicile and Giti=ensfiip i~ ths State of Ftorida that I am filing this day in acoordance and
~n co~formity with Chapter 222, Section 222.17, Florids Statutes.
Bird
I was forme~ly a legal resident of _~st Island Yinn '
~~~y~ (St~ro) ;
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anc! 1 resided at ~x 65 However I havs chanyed my domitile
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to and am and have been a bona fide resident of the State of Florida since day of
November _ , ~q 67 , an~ I reside at ~707 Y~ rQini s A~.s
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, lLORIDA
and this statement is to be taken as my declaration of citizenship, ectual legal residents snd domicile in the State of Floride. :
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(Insert here any pertinent facts, such as sale of property or business, or relinquishment of employment ~
at former domicile, ~emoval of family to new domicile, purthase of home, etc.) ~
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Entering Dbuglas in the 3rd grade
FII.E~ ANO RECOROEO~ '
ST.RFCORD VERIF ED~~ .
.~62231
'6T DEC I PN i: 0n6~
i ~tUG~?~ i~0t7RAS .
i CLERK CIRCUI7 COURT
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1 FURTHER CERTIFY that ! will comply with all other requirements of a leyal resident of this State.
I FURTHER CERTIFY that 1 have no intention to return to my former domiti~e, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLQRIDA, permanently.
~~i:ttct:r;.,~ 'r ~Anl~J' ~ '
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J , cNafl'1C~
, • - David Schleusener
Y,- : t/r
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1a' ~J ~
. . (Address)
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` ~J . ~ ~ . lst December 67
•~vij~ii,Lt~ ard subscribed before me this day of . 19
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ROGER POITRAS - j
CIRCUIT CQURT - - Notary Public ~
y ~
gy 7v O.C. My Commission expires ~
(To b~ ~x~cuNd in.dup~cab and oripie~al til~d with CIKk Ci~vh Cour1, aod duplicat~ with Tax At~or.)
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emK169 PRGE1105
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