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Decla~ation ot Domicile and Citisenship :
,
TO THE STATE AND COUNTY TAX ASSESSOR. ~63~~~
51. IUCIE COUNTY, FLORI~A:
This is my declaration of ~omicile and Citizenship i~ the State of Flo~ida that 1 am fili~g this day in aaoordance a~d
in conformity with Chapter 222, Section Z22.17, Florida Statutes.
I was forme~ly a legal ~esident of P4~tSmOUth RhOd! IS1aAd
(City) (Sta1e)
and I resided at 92 Qouglas Ave. Howevaf 1 have chan~ad my domiti~e
(Street and Number)
to and am and have been a bons fide resident of the State of Florida since 1 ~t,~ day of
_ Se~tembtr ,~q bT, and 1 restde ar 385 Sandia Drive Port St_Lucie ;
(Street and Number) I
FORT PIERCE, SAINT tUC1E COUNTY, FLORIDA
and this statement is to be taken as my declaration of citizenship, actusl legel residence and domicile in the State of Florida.
(Insert here any pertinent fads, such as sale of property or busineu, or relinquishment of employment
at former domicile, removal of famity to new domicile, purchase of home, etc.)
Establishing residence STR
UC E ~o~NT RDEO'
FcoRn vERrFYEO~A•
'68 JAN ~s3 ~c ~
3 ~ I I : ~'9'`~
~ ~o~~~ 1~o,r- .
LERK CIRCUIr ~`'S
COURT
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I FURTHER CERTIFY that 1 wil) oomply with all other requirements of a Isyal rssident of this State. ~
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1 FURTHER CERTIFY that I have no intention to return to my former domitile, and 1 intend to remain in FORT s
z
~
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. ~
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% - - ,:~i:;:: . ~C ~
• C~~`~.; (Name) ~
=
U-,;~~~';::~ • • ; t,~
; Cl inton A Higbee
~n •
y - c~r' ' ~
.9 ' ~ = _ (Address) ~
~ . '
: 3rd January 68 ~
- S~tro~p 3v~~n2! subsuibed before me this day of . 19 • ;
_ . ~
ROGER POITRAS
CIRCUIT COURT Notary Public
gy O.C. My ~ommission expires
(To b~ uacvt~d in duplicaM and ori~inal Rl~d wilb Cbrk Gra~if Courf, snd duplluN wiN~ Tax Aa~or.)
BatIK 16~7 P~G[ 2~ ~