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Declaratlon ot Domicile and Cltizenship ;
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T(~ THE STATE AND CDUNTY TAX ASSESSOR,
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Sl. IUCIE COUNTY, FIORIDA:
This is my declaration of Domicile and Citizenship in the State af Florida that 1 am-filing this day in accordance and
~n conformiry with Chapter 222, Section 222.17, Florida Statutes.
I was formerly a legal resident of 4 ~(f~ ~ ~/4~ _ _ _ _ _ E - -
. (City) (State)
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and I resided at ~ ~~K~~-A f
1l D_ E R R. Howe~er ~ ha~e changed my domicile
(Street and Number)
to and am a~d have been a bona fide resident of the State of Florida since - day of
. .7 ~t..~T _ , 19
~ 0, and I reside at `~~S~s ~ 1- ~ A ^'~E ~
_ - - -
(Street and Number) }
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f
WRT PIERCE, SAINT LUCIE COUNTY, KORIDA ~
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and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Flo~ida. j
(Insert here any pertinent facts, such as sale of property or business, or relinquishment of employment ;
at fo~mer domicile, ~emoval of family to new domicile, purchase of home, etc.) ~
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fILEO AND RECOROEp
~T. L11CIE COUNT~' fLA.
ROCER POITRAt
C~ERII CIRCUIT COIIRt
RECOR~ VERIFIEO~...~,~~
M~ur 29 II s6 ~M'11
' 206769
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~ 1 FURTHER CERTIFY that 1 will comply with all other requirements of a leya) resident of this State.
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~ I FURTHER CERTIFY that I have no intention to return to my former domiCile, and 1 intend to remain in FORT
~ PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. F
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~ (Name) ~ ~ ~',-~c. %N
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~.to~eitc~uk~3tribed before me this day of 1911_.
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~ ~ URT Notary Public E
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;i: By _ _ _ - D.C. My Commission expires i
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~ (To b~ ~x~cut~d in dupliuts and o~i~inal fil~d wjth Cl~rk Circuit Court, and dupllut~ with Tax Ass~swr.)
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