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D~cla~atbn of Domiail~ and CftlsM~hip 1'~'3;~`~
TO THE STATE AND COUNTY TAX ASSESSOR,
51. U1CIE GOUNTY, FIORIDA: .
This is my declantw~ of Domicile and Citisenship 1~ ths State of Florida that I am filirq fhis day in aooordanoe ~nd
in aonformity wlth Chapter 222, Sattia? 222.17, Florida Sfatut~s.
Hageratown
I was formerly a leqal tesid~nt of
(City) (Stah)
815 Armstrong Avenue
•nd 1 nsidsd at . HowwK 1 haw thupsd my domidlt
(sheet snd Numbs~)
to and am end have bsen a bona fide res'~dentt of ths Stste of Florids slnos NOV . 1 ~y ~
, 19~L$. and 1 r~side at Rt . 2, Box 2?69-B
(Street and Number)
~ORT !1~ SAINT LNCI~ COUNTY. RORIDA
and this :tatement is to be taken as my dedaration of citi~snship, actusi le~al residenoe and domidle in ths State of Horidi.
pnsert here amr pertinent facts, such as saie of property or business, or mlinquishment of emplo~yment
at former domicile, romoval of family to new domicile, purchase of hane, etc.)
Establishing residencq for homestead exemption ~ ~
FII.E~ AN ~OUN't'Y F~ '
ST. LUCIE vEA~F~ED
R~~
R~3
~69 JA 9 IW 9: ye ~ ~
ER PO?7RAS
~ , ~~aK cracviT covRT~
,
i
I
I FURTHER C~RTIFY that 1 will comply wifh all other roguirenwnn of a lepa! residsnt of this Stah.
I FURTNER CERTIFY that I have no intention to return to my fomner domivie, and I intend to remain in FORT
PIERCE, SA~,N?.U~E COUNTY, FLORIDA, permanently.
,ti,::itti::t,:"
J + ; ; ~t~ v ' ? .
~~.:5~`'~;k;jjc•: (Name) Roger e Keiiholtz
.a ' ~v~` i "a = ~ ,
~ J^~ : i ~ `#~t~. A.' . w Ii. • ~ _ .
- ' ~ -:l.';E~ ~ ' (AddfAti)
, ~ r ~ ...GO .
'Sworn ~o and wbsaibsd before me thi: 9th .january ~ ~q 69 ,
ROOER ~OIT~AS -
q~RK CpuRT Notary Publk
gy - O.C. My ~ammis:iore ~xpir~s
(Te b~ ~o~c~rNd i~ d~lical~ a~d o~i~inal fil~d wMl~ CM~Ic praAt Covet, apd ~ wi1M Taoc As~er,~
~ PA6E ~
u -
~ . _ _ V ~ ` 3e.