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O~cla~atio~ of Doml~ll~ and Citis~~si~tp
TO THE STATE AN~ COUNTY TAX ASSE5SQR,
Sl. tUCIE COUNTY, FIORIDA:
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This ~s my declsration of Domiule and Gitize~ship in ths Stete of Flo~ids that 1 am filin~ this day in accordence end
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~n confo?mity with Chapter 222. Section 242.17, Florida Statutes.
1 was formerly a legal resident of . - _C~B~~i.~~- _ - _~-~a88.
' (City) (Stets)
and 1 resided at _ BOX 13~ _ _ HOWeV~ ~ have chan~ad my domitile
(Street arid Numba~)
ro and am and have been a bona fide roaident of the State of Florida since .____._____~Q.#~'i._ dav of
-----June-- 19?~ , and I ~eside at _T__~.428 8yrotl St.
(Street and Numbe~)
FORT PIERCE, SAINT lUC1E COUNTY. RORlDA
and this statement is to be taken as my declaration of citize~ship, actual legal residence and domicile in the State of Ho~ida.
(I~sert here any pe~tinent facts, such as sale of property or business, or relinquishment of employment
at former domicile, removal of family ta new domicile, purchase of home, etc.)
(~iomestead Exemption) 2G~`~3
fIlEO ANO RECORQEO
SL~ltC1E COUMTY flA. ,
ROCER POITRAS
CIERK CItiCU1T COUBT ,Q~~
RECORO vERIFIEO.~.~L~
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Ju~ ~ 4 s~ PM'T!
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` I RJRTHER CERTIFY that I will oomply with afl other requirements of a le~al resident of this State.
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€ ! FURTHER CERTIFY that I have no intention to return to my former domiCjle, and I intend to remain in FORT
~ PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanensly. RBVmOAd H. Ford
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~ (Name)
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(Address)
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F Sworn to and subscribed before me this 4th day of January ~ ~9 71
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~ (T~,iri~'~~i;iw'~c~h and ai~in~l fil~d whh Cl~rlc prwM Coue~, and dupticat~ wHh Tax A~sror.)
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