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1'72132 '
~eclatation ot Domicile and Citi:enship j
i
TO THE S~ATE AND GOUNTY TAX ASSESSOR,
51. LUCIE COUNTY, FlORIOA:
This is my declaratio~ of Domicile and Citizenihip in the State of Florida that 1 am filin~ this day in aa,ordanos and
in conformity with Chapte~ 222, Ssction 222.17, Florida Statutes.
1 wss formerly a legal resident of NorWOOd Macca _h~~cPtts
(City) (State) f
and 1 rosided at 257 Pleac~n_t Street . However 1 havechan9ed mydomidle
(Street and Number)
ro and am and have been a bona fide resident of the State of Florida since bth day of
JUlY , 19 68 , and 1 reside a~ ~ah~ and INotei, Rt 3,F. Pert P~ PrCP_ _
(Street and Number)
FORT N~C~, SAINT LUCIE COUNTY, FLORIDA
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and this statement is to be. taken as my decla~ation of citizenship, actual legal residenae a~d domidle in the State of Florida.
(Insert here any pertinent facts, such aa sale of property or business, or relinquishment of employment
at former domicile, ~emoval of family to new domicile, purchsse of home, ett.)
Estabiish Residency
f ILTc~ AND RECOR0~01...
S7. WCI R~ vER1F
EDLA.. -
RECO
1`72132
' '68 NOV 14 PN 1: 3N
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~ r~OGcR ~OITRAS
~~EaK CIRCUIT COURT:
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I RJRTHER- Cf~tTIFY that I will oomply with al) other requireme~ri of a le~al r~idsnt of this State. ~
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1 H,~(~TH~R. CEitTIFY that 1 have no intention to retum to my former domicjle, and ! intend to remain in ~ ~
- t
~ FLORIDA, permanently.
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',1 ~'G'•. ~ .
~ ~ ~ J, ~ .
•~?3',.;~~` G: _ -
_ c y ; ` (Name)Chester Robert Hartshorn
' ' ~ _
J ~•~%••G~ ~ ;
• . ( heila May Hartshorn
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Sworn to and subxribed before me this 14th day of NnvpmhPr , ~q~~,
ROGER ~OITRAS
CLERK CIRCUII COURT Notary Public f
By D.C. My Commission expires
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(Te b~ ~aevbd in duplicab a~d oriainal fil~d whh Cl~elc Grark Cou~f, and dupli~at~ wiN~ Tax Asta~or.~ i
ra ±
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