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Deciaration ot Domicile and Citisenship '
TO THE STATE AND COUNTY TAX ASSESSOR. ~v~`7a7~
Sl. LUCIE COUNTY, FIORIDA:
This is my declaration of Domicile and Citizenship in the State of Florida that I am filing this day in aacordanoe and
in conformity with Chapter ~22, Section 222.17. Florida Ststutes.
1 was formerly a legal resident of A1ew ~aeretne Mi tseuri
(City) (State)
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and 1 resided at Rg~te 1 However I have changed my domit3le
(Street and Numbe~)
to and am and have been a bona fide resident of the State of Florida since 12tb day of
Au~ust , ~9 69 , and I ~eside at 109 Ri0 Nlar Coust
(Street end Number)
f4RT MQtCE, SAINT LUCiE COUNTY, RWtIDA
and this statement is to be taken as my declaration of citizenship, actual lagal residence and domicile in fhs State of Ho~ida. f
(Ins~t here any peNinent facfs, such as sale df ~perty or business, or relinquishment of employment ~
at former domicile, removal of family to new domicife, purchase of home, etc.)
Bntering Margo VanHoutan in iltb grade ~
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FILEO ~ND RECORDED
ST. LUCtE COUNTY. FLA•
G~,~~; ~'c~ti~lEG
18399`~,
'69 OCT 7 PM 2 .
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I CLERK ~~R~Ul7 COURT
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1 FURTHER CERTIFY that 1 will oomply with all other requiremenfs of a le~al resident of this State.
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I FURTfiER CERTIFY that I have no intention to retum to my former domicjle, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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(Name} y~s.~erroid H. YtaHoutaY!
(Prancea)
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~ ~ ~ October 69
~J ~w~ql:to ~}ad,-~r~sgcribed before me this 7th day of 19 .
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~tIRT Notary Public
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By ` O.C. My Commiss'wn expires
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1To b~ ~x~euhd in duplieat~ snd ori~inai fil.d w~ q.~lc CireuH Court, snd duplka~. wHb Tax At~u~a.)
BooK 180 ~ 94~
No. 13
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