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Declaration ot Domicile and Citizenship ~
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TO THE STATE AND COUNTY TAX ASSESSOR,
Sl. LUCIE COUNTY, FLORIDA:
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This is my declaration of Domicile and Citizenship in the State of Florida that 1 am filing this day in accordance and
~n conformity with Chapter 222, Section 222.17, Florida Statutes.
1 was formerly a legal resident of ~~hVille _ Nt~rth C8rO11D~
(City) (State)
20 Forrest Road
and I resided at _ ` _ _ _ _ However I have changed my domiCile
(Street and Number)
to and am and have been a bona fide resident of the State of Florida since Zst_. _ day of
November , ~9
67_, and I reside ar _ 325 Moroingside Blvd -
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
and this statement is to be taken as my declaration of citizenship, act~al legal residence and domiciie in the State of Florida. ~
, (Insert here any pertinent facts, such as sale of propery or business, or relinquishmeni of employment ;
at former domicile, removal of family to new domicile, purchase of home, etc.) `
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_ .
fistablishing residence ,
FI~EO AND RECOROEO ~
ST, LUCIE COUNTY. FLA.
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CLERK CIRCUIT COURT :
1 FURTHER CERTIFY that I will comply with all other requirements of a legal resident of this State.
I FURTHER CERTIFY that i have no intention to return to my former domi~ile, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. ~
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f;tl I i,,,C'~i,,
V\''• ~.~3 : p(~`%~ ~
~ . Brooks~$dwa d Rogers n #
-N` .i - . ~ ~;a - ~ ~
'.'y~ V[r~~ ife 3
; ~ ~ Freda M. Ro rson ~
_ - ~
` 19th Februarq 68 ~
Sworn to and subscribed before me this day of ,~q .
ROGER POITRAS '
LERK CIRCUIT COURT Notary Public
BY D.C. My Commission expires
(To bs oxecuted in duplicate snd original fited with Cl~ric Grcuit Court, and dupliute with T~uc Assessor.j :
BO~K~7O PAGEI~~T .
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