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Declaration ot Domlcile and Citisenship
TO THE STATE AND COUNTY TAX ASSESSOR. 163504
51. LUCIE COUNTY, FLORIDA:
This is my dedaration of Domicile and Citizenship in the State of Florida that I am filing this day in accordance and
~n conformiry with Chapter 222, Section 222.17, Florida Statutes.
Ma lewood New ~ersey
I was formerly a legal resident of _ ~ _ - -
~C;~y~ (State)
and 1 resided at ___35 CODCOrd Ave, i_____ _ _ _ . However I have changed my domic,ile
~
(Street and Number)
to and am and have been a bona fide resident of the State of Florida since _llth _ day~ of
Novenbe1 67 221 Osceola ~'t
- - - - , 19---, and I reside at
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, fLORIDA
and this statement is to be taken as my declaration of citizenship, actual tegal residence and domicile in the State of Florida.
(Insert here any pertinent facts, such as sale of property or business, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
Establishiag residence
FILED AND RECORDED ~ILED ANO RECORDED
ST. LUC1E COUNTY^FLA. ST. LUCIE COUNTY. FLA.
ttE_C~ ~~~'•''~"~`'t{~ RECORO `lERIFIED
163504 163?254
' '~g I S PM 2: 00 '68 JAN 4 I~ t2 : OS
-~d~j ~ •
~ . ~ _ t:O~E~ n ~ O! ~ R~S
" ' ` CLERK CIRCUIT COURT
' - C~~RK ClRCUIS COURT
- ~j-_ ~ ~ZI~,e.~~ .
/
~ .
1 FURTHER CERTIFY that 1 will comply with all other requirements of a legal resident of this State.
1
I FURTHER CERTIFY that I have no intention to return to my former domiule, and I intend to remain in FORT
PIERCE, SAINT LUCIE.~OUNTY, FLORIDA, permanently.
• ~ : ~ir/ _ a~C~~
~ ~ ' ~ (Name)
- - .
~ _ " • - ~1a r ga re t M. Rowe
~
, _
~ ~ ~ ~ ' - (Address)
-
~ : . ~ ^ ~ ~ t
~ Sworn to and subscribed before me this _ 4th day of - ~8I18uiy ~ ~q~$
~ ROGER POITRAS
~ CIERK CIRCUIT COURT Notary Public
~
gy ~-a-~~ D.C. My Commission expires
~
_ ~
(To be executed in duplicate snd originsl filed with Clerk Grcuit Court, snd duplicate with Tax Ass~sfor.)
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60~R ~ s V~i1GE t7t7 E~~~ ~E~~
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