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Declaration ot Domicile and Citizenship ~
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TO THE STATE AND COUNTY TAX ASSESSOR, 164`743 ~
Sl. LUGE COUNTY, FIORIDA:
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This is my declaration of Domicile and Citizenship in the State of Florida that I am filing this day in accordance and t
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in conformiry with Chapter 222, Section 222.17, Florida Statutes. .
Cullowhee North Carolina
1 was fo~merly a legal resident of _ _ . _ _ . _ _ -
(Ciry) (State)
P.O. BOX 33 However 1 have chan m domiqle ~
and I resided at --_T. - - - - - 9~ Y
(Street and Number)
to and am and have been a bona fide resident of the State of Florida since 26 th _ day of
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Au gu s t__-_, 19-_6,~and t reside at 502 ~'1a~f lorte s La~1e
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
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 relinquishment of employment !
at former domicile, removal of family to new domicile, purchase of home, etc.)
Bst4blishing residence ~
FILEO ANO RECORDED ~
ST. LUCc~ COUNTY, Fl,q, `
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'68 FE6 2 7 pM • 43 ~
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CL~RK~ -~+~c ~ R ?
CIRCUIT COURT '
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I FURTHER CERTIFY that 1 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 domic,ile, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently_
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_ '•r~. , (Name)
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Herbert Swain Pendergraft
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, 68
- Sw~a to~elld~subscribed before me this 27th day of Feb. ~ ~q _
ROGER POiTRAS
LERK CIRCUIT C URT Notary Public
By U.C. My Commission expires
(To b~ executed in dupliwte and originsi filed with Clerk Grcuif Court, and duplicste with Tax Assessor.)
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