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. ~luatio~' of Oo~iail~ a~d Citis~nshlp ~
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TO TNE STATE ANC COUNTY TAX ASSESSOR,
Sl. lllClE GWNTII. RORIOA: -
Th1s i: my d~clar~tion of Domicil~ and Citi~ship in th~ Sr~a of Florida H+a~ 1 am filinq tht~ day i~ ~dana ~nd
in' aonfatmity with ChaptK 2~2. S~ttio~ 24~.17, Florida St~fuht. .
1 was forn~ly a Ipai nsid~?t of BOOIIA HOTth C8x'011II8
- tGM tstn+)
~nd 1 ra~ded at 1821 8111tOp DY'. I~~
- (Stn~t and Numbu)
ro and ~m and havs been ~ bona fidt nsid~nt of tM Sta» o# Florida dna 3Z'd ~y ~
June 19 70 ~ 112 1Yset alenn Dr.
(StrMf snd NumbK)
~ORT iAMIT LiiCl! C011NTY. lLORqA
and this st~tsment i: to be taken as my declantion of dtizsnship, ectual Ipal re~ider+o~ and domkili in th~ State of Floride.
(Insert he~e any ps~tinent facn, such ~s sale of propKty or businsss, or rolinquishment of ~mploymu~t
~ at formsr domkile, rsmoval of ferMiy to nsw domkile, purchas~ of home, etc.)
(Ho~e+atead mcemption)
_ . "FIL~D ANO R~_t~J1p~0~
- ST. LUCIE CO NTY. FLA
- RECORD YERI~IED
. _ 196948
'10 Al~ I 0- AM 10 : 30
i
~ ROGER POITRAS
CLERK CIRCUIT COURTf
I FURTHER CERTIFY th~t 1 wlll oomply with all oth~r nquir~n~nri of a Ipal raid~nt of thb Stah.
t FURTHER CERTIFY that 1 have . no intention to retum to my former domivle, and I intend to ~emsin in FORT
PIERCE, SAINT LUCIE COUNTY, FLORI~A, permsnently. S8~ Thompeon ,
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(Nam~)
U1ddr~ss)
Sworn to ~~E'~,`'r~b4d bsfore m~ thi~ lOth ~y ~ August 19
. ` 1 ..Iy"!': ~".'s .
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. Notary Publk
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gy O.C. My Commission expir~s
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