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Declaration ot Dosr.!cile and Citisenship ;
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TO TNE STATE AND COUNTY TAX ASSESSOR, 165~~,r, '
o~f !
51. LUCiE COUNTY, FLORI~A: (
This is my declaration of Oomicile and Citizenship in the State of Florida that I am filing this day in aecordance and
in conformity with Chapter 222, Section 222.17, Florids Statutes. ~
1 was formerly a legal resident of NeOD Yen tucl~v
~~;ty~ (State)
and I resided at However t have changed my domivle
(Street and Number) !
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to and am and have been a bona fide ~esident of the State of Florida since Sth _ day of
November
_ - , 1966 , and I ~eside at ~~Shl~~t_. c+rePt
(Street and Number)
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FORT PIERCE, SAINT LUCIE COUNTY, RORIDA ~
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Ho~ida. t
(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.)
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Bstablishing residence
fILEO ANb RECOROED~
ST. LUCIE COUNTY. FLA. ,
RF:CO~~J V~R!FIFD
165668 :
~se ~ z9 P~ ~z: 09
ii0'vE~R i'OITR:.S
CLERK CIRCUIT COURT
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1 FURTHER CERTIFY that I wil) oomply with al) other requirementa of s(ega) resident of this State.
I FURTH~CERTIFY that I have no intention to retu.m to my former domic~le, and I intend to remain in fORT
PIERCE, SA!{11T'l1~1~%~COt1NTY, FLORIDA, permanently. #
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- ;r ~ " . : ' ~o ' (Name)
T ~ ' - Herman Hall
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Sworn to and subscribed befo~e me this 29th day of Ir1SrCh , 19~.$.
ROGER POITRAS
CIRCUR OURT Notary Public
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gy D.C. My ~omm~ssion expires
(To b~ ~x~cut~d in dupl~ut~ and ori~inal Fled with q~rlc Circvit Court, and duplica» with Tax Ass~ssor.)
gooK 171 P~~E 434
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