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Declaration ot Dorriclle and Citizenship
TO THE STATE AND COUNTY TAX ASSESSOR, ~ ~
Sl. IUCIE COUNTY, FtORI~A 2t~[~r~r~c~
This ~s my declarat~on ot ~om~c~le and Cit~zensh~p in the Sta~e of Florida that 1 am fil~ng this day in accordance and
conformity w~th Chapter 222, Section ?22.17, Florida Statutes.
I was formerly a legal resident of . ~f~ ~/1/ ~ ~-~K ~r-
(C~ty) (State) ,
and I resided at ~~~~S~e~~?-(iGs~ - Nowever I have changed my domicjle
(Street and Number)
ro and am and have been a bona fide ~esident of the State of Florida since day ot
, 19~0 , and I reside at ~S,S •
(Str~Number) -
FORT PIERCE, SAINT IUCIE COUNTY, FIORIDA
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 pert~nent facts, such as sale of property or busi~ess, o~ relinquishment of employment
at former domicile, removal of famiiy to new domicile, purchase of home, etc.)
~QntQ..a'~" ' F~~E 0 ati ~ A E C4i;~pE~ 1
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~ f FURTHER CERTIFY that i will comply with all other requirements of a legal resident of this State.
I FURTHER CERTIFY that I have no intention to return to my former domic,ile, and I intend to remain i~ FORT s
~ PIERCE, SAINT LUCIE COUNTY, FIORIDA, permanently. `
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Sworn to and subscribed before me this day of l~ 1911. '
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- ROGER P017lAS - - - - - - - - -
'C1~RK CIRf~l~~COU~T ~ _ Notary Public ~
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3y T ' 2~~~:_ D.C. My Commission expires - - -
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~To b~ sxecut~d in duplicsts and oripinal fil~d with Cl~rlc Circvit Court, and duplicat~ with Tax Assessor.)
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