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Oeciaratio~ ot Oomicile ~nd Citizen~hip ;
163003
TO THE STATE AND COUNTY TAX ASSESSOR,
Sl. IUCIE COUNTY, FLORIDA:
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This is my declaration of Domicile and Citizenship i~ the State of Florida thst 1 am filing this day in attordante and ~
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~n co~fo~mity with Chapter 222, Section 242.17, Florida Statutes. ~
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1 was formerly a legal res~dent of _Kiqg_s~ort _ Tenn. ;
(City) (State)
337 ~irgil Street . Howe~e~ i have cha m domic~le
and i feSiCI6~ af ~ y
(St~eet and Number)
ro a~d am and have been a bona fide resident of the State of Florida since 1~Lh. - day of
_~~e~b~~ 19
67_, and I reside at 110 BOQitB COUrt _
(Street and Number)
FOltT PIERCE, SAINT LUCIE COUNTY, RORIDA
and this statement is to be taken as my declaration of citizenship, actual legal resiaience and domicile in the State of Horida.
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(Insert here any pertinent fads, such as sale of propery or busi~ess, or relinquishme~t cf employment ~
at former domicile, removal of family to ~ew domicile, purchase of home, etc.)
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$stablishing-=residence and will apply for homestead
FILED AND RECOROED
S7•~U~O~^ ~FR1f EOLA~ ~
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'67 ~EC 26 At~ IU : 54 - ;
163~3 T
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I CLF RK CIRCUi7 COURT ~
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1 FURTHER CERTIFY that 1 will comply with al! other requirements of a legal resident of this State.
I FURTHER CERTIFY that t have no intention to retum to my former domicjle, and 1 intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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j~~ IC~!fo (Name)
- T. R. Lewis
- ~~0•
^ • r • r
' (Address)
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SG~r~rfr~~~ndiubsuibed before me this 28tb day of Lecember ~ jq 6?
ROGER POITRAS
CIRCUR COURT Notary Public
gy ~bt~ D.C. My Commission expires
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(To b~ ~x~cutsd in duplicat~ a~+d ori~inal fil~d vrith C~xk Grwit Court, snd duplicah with Tax Ass~or.)
d00lt1Va~ PAG[~~02
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