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O~cluation ot Do~nlcit~ a~d Cittz~nship
TO THE STATE ANO COUNTY TAX ASSESSOR,
Sl, lllClE COUNTY, FIORIDA:
This Is my declantion of Oomidle and Citi~oenship in ths Staro of Florida that 1 am filinq this day in aaoadano~ a~+d
in conformjty with ChaptK 222. Settjon 2Z2.17, Florida Statutes.
I was formsrly a Ipal ~esid~nt of Nit ro West V i r gin ii ~
(CItY) (Stah)
snd 1~~d.d at 11 S 5 Fi rs t Ave So . ~K my
(Sheet and Number) ~ .
ro and sm and have bee~ a bor?a fide rosklsnt of th~ State of Florida si~os .1uDe 15 ~y
, ~9 68, and i ros~de at 104 Bast priaa Vista Blvd.
~ ~ snd Number)
l~ORT M~E, SAtNT WCIE COUNTY, fIOR~A
and this statement is b be taken as my declaration of citizenship, adval legal r~idenoe and domicile in the State of Horida.
qn:ert hero any pertinent facts, such ss sale of property or busineu, or telinqui~m~nt of employment
at formar domicile, renwval of family to new domicile, purchase of hane. Mc.)
fintering chiidren in scbool •
FILEO AND RECORDEO
ST. ~UCIE COUNTY. ~LA.
RE:COR~T `lERIFiCC?
1'70(~38
~ '68 AUC 2 9 AM i I: 0 0
:
~
~ ROG~R ~OITRAS
~ CLERK CIRCUIT COURT
l
~
1 FURTHER C~RTlFY that I wiil aompiy wHh all oth~r nquiremenb af s Ipal rs~dsm of this State.
I FURTHER CERTIFY th~t 1 have no intention to retum to my former domicjle, and I intend to remsin in FORT
PfERCE. SAINT WGE COUNTY, FLORIDA, permanently.
~ 1 (Nsms) Hele M. hapman
~Z ' j _ e ~ re - -
. f r
' n ' ' -
• ' - . ~ t; :
~ ~ . _ ~ ~~f
Sw~o r~
b and wbsuib~d b~~or~ m~ this 29th ~y ~ August ~~q 68 ,
tOOiR ~OITRA:
Ct~K Cl~CINT Notary Publk
by O C. My ~onunissio~+ ~xpi~u
R. w«»w~i M~Ma~ .~i ~yiwr al~i wi~M a..k ci~wr c«~. .r ~li..~. ,~ri~ T.~c A......ra
. . ~i73 f~10~.?
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