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Decla~ation ot 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 conformiry with Chapte~ 222, Section 222.17, Florida Statutes. ~
I was formerly a legal resident of Burlington _ _ _ Conn. _
(C;ty,) (Stare)
a~d 1 resided at Ge0 Wa3hitlgtOD TurDpik! However I have changed my domiCi~e
(Street and Number)
lSth ~
to a~d am and have been a bona fide resident of the State of Florida since day of
69 ~
Jao~ary__ , iq
S0, end t reside a~ 130 Seranta Court
~ (Street and Number
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
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 pertir•ent fads, such as sale of property or business, or relinquishment of employment
at former domicile, ~emoval of family to new domicile, purthase of home, etc.) f
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Bstablishing residence
FI~ED tiND RECOROED t
, ~T. ~UC!E COUtiTY, FL:,. '
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_ . ~ 6 AM 9 : 56 ~
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i C! EF?K Ct:? ;~tT COURT
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I FURTHER GERTIFY that I will comply with all other requirements of a lega) resident of this State.
1 FURTHER CERTIFY that I have no intention to return to my former domicile, and I intend to remain in FORT
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PIERCE, SAINT_.LUCIE COUNTY, FLORIDA, permanenHy.
M~ry B~N~r~ardt
;2 , . . .
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, (Address)
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~ Sworn to and subsc~ibed before me this 6th day of Tanuary , ~q 70
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~ ROGHt POITRAS
K CIRCUIT OURT Notary Public
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~ By D.C. My Commission expires
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(To be exscuted in duplicate and original filed with Clerk Grwit Cour1, and duplicats with Tax Assss~or.)
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~ b00K PAGE 213 `
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No. ! 3
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