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Declaration ot Domicile and Citis~nship ~
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TO THE STATE AND COUNTY TAX ASSESSOR. ~
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Si. LUCIE COUNTY, FLORIDA:
This is my declaration of Domicile and ~iti2enship in the State of Flo~ida that 1 am filing this day in acoordanoe and
in oonformiy with Chapter 222, Sectio~ 222.17, Florida Statutes.
I was forme~ly a legal ~esident of ~~ti~Orc ~ -
(City) (State)
and 1 resided at _ 10526 Gateridge Rd. COCteysville ~wever 1 have changed my domiu~e
(St~eet and Number)
to and am and have been a bona fide resident of the State of Florida since 30 + day of
, 19 69, and I reside at p• 1S6
(Street and Number) ;
FORT PIERCE, SAINT LUCIE COUNTY, FLOitIDA ~
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and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Ho~ida. ~
(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 residency
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~ ~llEO AND RECORDED' E
ST, lUC1E COI~NTY, F~A. ~
Rf:co~~v,~145 ~
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'69 JUN 4 PM 3' 6 ~
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ft~~GEr~ POiTRAS
CLERK CIRCUIT COURT~
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I RJRTHER CERTIFY that 1 will oomply with all other requirements of a legal Yesident of this State.
I FURTHER CERTIFY that I have no intention to return to my former domiale, and I intend to remain in FORT ~
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PIERCE, SAINT LUCIE COUNTY, FLORIDA, permane~tly. ~
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(Name) rid Cul ~=t~~q
Sorenae~
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~ - . ~ . . - , (Address)
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~ ~ f:~woM tv.e~~ubscribed before me this 4tb day of JV~! ~ 1969 I
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r + ROOERs ~€POITR/?S
~ CLERK CIRCUR COURT Notary Public
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~ By D.C. My Commission expires
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~ Re b~ ~x~nrhd In dupliuN and ori~insl fil~d with Cl~rlc Ctra~it Cour~, and dvpliuh wf16 Tax A~~o~.)
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eooxl~$ ~t~ 5'~
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