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~claration ot Domicil~ and Cittsenship . ~~~~3
TO THE STATE AND COUNTY TAX ASSESSOR,
~l. ItJCIE COUNTY, FLORIOA: ~
This ii my declantion of Oomicile and Citise~ship, in the State of Florida that I am fili~q this day in aooordano~ a~d
in oonformity with Chapter 222, Sattio~ 222.17. Florida Statutes.
1 was formsrly a Ipel rosid~nt of Cuye?ho~a Palls Ohio ;
~Ciy~ (Sta») ~
a~d i~~ded at 1648 nineteenth street , Ho~„~evsr 1 have chan~ed my domicile
(Street and Number)
ro and am end havs been s bona fide resident of the State of Florida sirtoe 15th day of
Februar y , ~q 68, and ~ reside at 909 Jackson Way
' (5treet and Number)
E4RT ~ SAINT LUCIE COUNTY, RORIOA
and this statemsnt is b be taken as my deciaraYwn of citiunship, actual legai residente and domicile in the Staro of Hotida.
qnsert here any pertinent facts, such as sale of property w business, or ~elinquishmer~t of employment
at former domiule, removal of family to new domicile, purchase of home, etc.)
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, Bstablishing residence and applying for homestead
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RE~ R~~~ t?
F11.E~ AN~ O~'A~ t
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i FURTHER CHtTIFY that 1 wiil aompty with all othar roquirements of a lepal r~ident of this State.
I FURTHER CERTIFY that I have rw intention to return to my former domicGle, and I intend to remain in FORT
PlERCE, SAINT UICIE COUNTY, FLORIDA, permsnently.
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.:t~`~'S1: .:r. .,r, ~ / f ~
• ~ . ~ • f /L / •
" (Nsfne) f
~ ~ ' ~ " John W. Chapin ~
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qhn %end'~substribed b~for~ me thi: 13th ~y ~ Janaurq 19 69 .
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ROO~R 'OITRI?~
~ Notary Public
a~.~.l,c~ ~~eTc.~i~
By D.C. N?y Commissi«+ .xpi~
a• .eo.ail~ M~lis.~. .~i .~i.M.~ w.~ wMM a«k draif c.w+, .~i inplicN. ,~,i~b Tavc A....».a
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