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Declaration ot Domicile and Cttize~ship ~
163991
TQ THE STATE AND COUNTY TAX ASSESSOR, '
f
Sl. LUCIE COUNTY, FIORIDA:
This is my decla~ation of Domicile and Citizenship in the State of Flo~ida that 1 am filing this dsy in atw~danoe and
im m~formity with Chapte~ 222, Section 222.17, Florida Statutes.
I was forme~ly a legal resident of Bainbridge Georgia
(~~tY) (State)
and I resided at ~ 905 AliC@ Stxect However 1 have changed my domiGle
(Street and Number)
to and am and have been a bona fide resident of the State of Florida since 28th day of
December__ _ , 19 b7, and ~ reside at 118 Garden Ave. ~
(Street and Number)
FORT~PIERCE, SAtNT LUCIE COUNTY, RORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Florida,
(Insert here any pertinent facts, such as sale of property or business, or relinquishme~t of employment '
at former domicile, ~emoval of family to new domicile, purchase of home, etc.)
~
Bstablishing residence _and applying,.fnt homestead
FILED AND RECORDED
S7, I,UCIE COUNTY. FLA.
RE CQ~+D VE~IFt~D
163991
'6$ 31 Pt~ 3: 41 ~
o~~~~
~ :;F:r'. i=OtTR~s
Ct~tRK CIRCUtT COURT
I FURTHER CERTIFY that 1 wilf oomply with al) other requirements of a legal resident of this State.
i
I FURtF1ER CERTIFY tnat I have no intent+on to return to my former domi~ile, and I intend to remain in FORT :
PIERCE, SAINT LUCIE COUNTY, FIORIDA, permanently. " ~
s `i~ylll:liiit•r~~ y ~ .
'':~.~•c-,'~', , ~''r'C~~i,ir~ (Name)
'v' ..;>'~;'i
;ic~!'"qji',l J. B, lalcCullough
•'I ._j'~~ ! i ~G~: ~ _ C ~
, , k
. ' .~~f~~
• r:~ Fi~
~j-
~ =v ' Margaret IrkCullough
'~C = - .
Sw~fil.ip;~Ai~sab~ibed before me this 31St day of ~anaury 19 68 ~
•
ROGER POITRAS
CIRCUIT COURT Notary Public
gY D.C. My Commission expires
(To be ~xeeubd in duplicah and oriQinal Aled with q~rk Circvit Cou~f, and duplieat~ weth 7ax Ass~s~oir.)
800K ~ U PACE 94~
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