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O~alaratlo~ ot Oomfall• ar~d CItlsMShip !
TO THE STATE AN~ COUNTY TAX ASSESSOR,
Sl. IUCIE COUNTY, FIORIDA:
This ii my decla~ation of Oomicile •nd CitiZenship in th~ Stat~ of Florida that 1 am filin~ this dey in acoo~danos and
in oonformity with Chaptet 422. Settio~ Z22.17, Florida Statutts.
1 was formerly a leyal resident of e u. a ~ d.
(City) (St+t+)
and 1 resided st O ~ o R N o r ~ y~' HowevK 1 have cha~psd my domic~le
(Strest and Number)
ro and am and have been a bona fids resident of the StaM of Florida since l It ~ T dsy of
_ v ~ t T , 19
1 Q, and I roside d ~ 4 0~ N l~? ~ k 1 v~
(Strsef and Number)
FORT PI~CE, SAMIT LUCIE COUNTY, RORIDA ~
and this statement is to be taken as my decla~ation of citizenship, actual leyal residenoe and domitile in the State of Florida.
(I~ssrt here any pertineM fact:, such as sale of. property or business, or relinquishment of employment
~ at former domkile, removal of family to new domicile, purchase of home, etc.)
Homeatead
ST
UCIE ~ RECORDEp
ROCER p~tpAS
1A-
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RECORQ YER f1ED C~~~
k ~ 20 3 ~ ,
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k 2Q~~3
6
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~ I FURTHER CHtTIFlf that I will aomply with all othK r~quiremsnts of e lepai raide~t of this St~».
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I FURTHER CEitTIFY that 1 have no intention to retum to my former domidle, and 1 intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. HAROLD E. SULLIVAN .
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' _ C p (Name)
1 So 3 T3 tWN~~r ~~?v -
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%~~~oKO~p.~p+~rx~ ttbstribsd before me this ~ V day of , 19
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i,.~.~,... • .
ROGER ?ORRAS
CIRCUIT COURT Notary Publk
.
8y O.C. My Commiuion expires
(Te b~ ~x~w~ad .ie dupltcsb and a~ioiaal Al~d whb Clwlc ClrarN Coue~, and d~pliaN wMl~ Tax A~r.I
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