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Oeclaratioin of Domicile and Citizenship
~.81~56
TO THE STATE AND COUNTY TAX ASSESSOR,
Sl. IUCIE COUNTY, FIORIDA:
This is my declaration of Domicile and Citizenship in the State of Florida that I am filing this day in accordance and
in conformity with Chapter 222, Section 222.17, Florida Statutes.
I was formerly a legal resident of JaCIrSO>0 ~IiCh~gal>I
(City) (State)
and 1-resided at X203 CT=rtr Tlri~ _ __ __. However I have changed my domicjle
(Street and Number)
to and am and have been a bona fide resident of the State of Florida since ~~
day of
April tq 69 and I reside at 901 Bel Ct_
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, RORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Florida.
(Insert here any pertinent fads, such as sale of property or business, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
DBBOitA)i ANN DeHART 16 years 11th grade
1817'56
FILED ANO RECORDED'
ST, LUCIE COUNTY. FLA.
RECORD VERIFIF_0
'69 AUG 12 AM I I : S7
ROGER r OITR~S
CLERK CIRCUIT COURT;
1 FURTHER CERTIFY that I will comply with all other requiremenri of a legal resident of this State.
1 FURTHER CERTIFY that I have no intention to return to my former domiG~le, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. /~~'~ ~~~"""' /j~~~~,_,
- ''~ l@t,3. JACK MYBRS/i
'~ ~• - - - ~ (Name)
- • • ~ S~Ol Bei Ct. , Pt. Pierce,
.~ ~i.
v Swdm~to~and subscribed before me this
la
ROGER PORRAS
RCUIT COURT
By ~- D.C.
My Commission expires
~. i a
(To be executed in duplicate and orisin~~l~ !'~ Court, and duplicate with Tax Asaesaor.)
-_ :~ ;~ .
(Address)
Plorida
day of August ~ 19 .i9
Notary Public