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Decl~ratlon ot Domicile and Citts~nship ~
209'741 ;
TO THE STATE AND COUNTY TAX ASSESSOR,
Sl. IU~IE COUNTY, FLORI~A:
This is my declaration of Uomicile and Citize~ship in ths State of Florida that I am filing this day in accordancs and
~n conformity with Chapter 222, Section 222.17, Florida Statutes.
I was formerly a legal ~e:~de~,r of ______Bentonherbor _ _ _ I[ich. _ _
(City) (State)
and I resided at ~ 678 K1II~ Ave. . However 1 have changed my domicjle
(Street and Number)
to end am a~d have been a bona fide resident of the State of Florids since __30tb day of
April_------ . 19?~ a~d I reside at 5108 Te][88 C~.
(Street snd Number) ~
FORT MERCE, SAINT LUCIE COUNTY, FLORIDA
and this statement is to be taken as my declaration of citizenship, actua! legal residence and domicile in the State of Flo~ida.
(Inse~t here a~y pertinent facts, such as sale of property or business, or relinquishment of employment '
at former domiciie, removal of family to ~ew domicile, purchase of home, etc.) '
(School Children)
j~~~ 11M0 RECOR t~
c~E cOUNtr ~LA.
Debbie Ray - 3rd Grade ~I.ERKCCIRC~iT COUIIT
itECORG Y[R~II 0
~Y Z~ ~0 ~1 ~ ~
209'741
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~ 1 RIRTHER CERTIFY that I will oomply witfi all other rsquirements of a Is~al resident of this State.
1 FURTHER CERTIFY that I have no intention to retum to my former domitife, and 1 intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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~ (Name)
~ Carolyn Beeeette (Mrs. Norman)
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~ (Address)
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~ Sworn to and subscribed before me this 26th day of ~8~ - , 19 .
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ROGER ~OITR/?S
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~ CIRCUIT ~ ~`''•t ~~'r',. Notary Pubiic -
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g ~ ~~.C. p~ My Commission expiros
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~ R~ b~ ~x~cut~d in dupNcat~ and'" . At~d v~jlb Cl~lc Grcuh Cou~f, a~d duplic~t~ witb Tax AtNSwr.)
~ ~ ~ ~ ~~xi92 2i04
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