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Declaration of Domicile and Citizenship
TO THE STATE AND COUNTY TAX ASSESSOR,
Sl. IUCIE COUNTY, FLORIDA:
This is my declaration of Domicile and Citizenship in the State of Florida that 1 am filing this day in accordance and
in conformity with Chapter 222, Section 222.17, Florida Statutes.
I was formerly a legal resident of ~~+ enn
(City)
and 1 resided at
____ Madison, West Virginia ---
(Street aril Number)
Wet 3.
(State)
However 1 have changed my domicile
to and am and have been a bona fide resident of the State of Florida since August 29 ~ -day of
19 69, and 1 reside at 1021 Beach Court
(Street and Number)
FORT PIERCE, SAINT LUCIic COUNTY, FLORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Horida.
(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.)
I am the guardian of James Michael Bunch, rvho will live with
me permenantlq and attend public schools here.
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1 FURTHER CERTIFY that 1 will comply with all other requirements of a legal resident of this State.
I FURTHER CERTIFY that I have no intention to return to my former domicle, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
(Name) Harold Hillman
(Elddress)
~~~,.,~~a:u.r,;~~`~,
' 2nd day of S ! tpmt>p 19_.b.Q.
=''f}'~~~w~f~~~~d,subsuibed before me this •
~~- '~,~ ROGER-EF~t
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l~ COURT Notary Public
gy' ~ f ~ .K. ~ w ` D.C. My Commission expires
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(To be oxewted in dupliate and origi 0 R ~ with Cleric Cirwit Court, and duplia» with Tax Assessor.)
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