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Oeciaration ot Domicile and Citizenship
TO THE STATE ANO COUNTY TAX ASSE~SOR. 2140~0
Sl. IUCiE COUNTY, FLORIDA:
This ~s my declaration of Oom~cile and Cit~zensh~p i~ the Stare of Flo?ida that I am filiny this day in accordance a~d
~n conformity with Chapter 222, Section 242.17, Florida Statutes.
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I was fo~merly a legal resident of 3 t',h ~ lZ _ ~_I_Q L'l~~O
~C;ty~ (State)
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c c „ v
~01 ~ d 1.(,. ~ d
and I resided at c~, J o~ o r~ _ ~ 0~ 1v However I have changed my domiClk ~
(Street and Number) -
ro and am and have been a bona fide residern of the State of Florida since _ day of
C1 ~ ~l -7 C ~ n ~ ~e__(_~ ? _ e _m ~ rci_r ~
t ~,C~ e S , 19_ and 1 reside at ~ h~ -
(Street and N mber) ;
~ ~,1.~ Cl r~ 1(~ ~j o rv~ e ~ O ~ e i
FORT PIERCE, SAINT LUCIE COUNtY, FLORI~A d t' V e Y. e u t. Q? e t'~ e~
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and this statement is to be taken as my detiaration of citizer~ship, actual legal residence and domicile in the State of Florida.
(Insert here any pertinent fatts, such as sale of property or business, or relinquishment of employment
at former domicile, removal of family to new domicile, purch~se of home, etc.)
' ~nr~e ~~,~n~ /~1,//er- fJp?-,~l ~9~~ R,~e ~a'
~~~r.~'~'~` L.eu~,~S /~Ir~ll~r ~e6 ~~GG t~~e//
e r A l~ ~ra n ; 1 I P r ~r',~~~ 7, 1 I ~c i a~y c/~
! S r,e Ia, 1 9~'~ e~
~ RrJf) ~~~u~,;r ~ 1ler ~ u
f?LEO ANn qECORpSp
'sj. tUCIE COUM?~1~ FL~.
~IERK IRCYt~,
pajp~ l~
'RECORD vfR~FiEC ~
214020 ~ 16
AWAITING ~'OBII,E HOME TO BE DELIVERFD TO FORT PIERCE, ST. I,UCIE
I
COUNTY, FI,ORIDA
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1 FURTHER CERTIFY that I will comply with all other requirements of a legal resident of this State.
I FURTHER CERTIFY that I have no i~tention to return to my former domicile, and I intend to rernain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. R.ALPH I,. ~lII,L~R
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- ,~,~~~'i~': ' 'i•• ~ - _ ~ - - -
• - . ~ .z _ (Name)
: _ ~ ~ 1 "
. ~ 'Jv~ ~ . .
' ~ ~ Pierce, Fla.
_ : . ~ ~ : . _GENERAL DII,IVERYi Ft.
~ " ~ _ - -
~ : , (Address) 33450
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;~=S~hi.o~ to.orid subscribed before me this day of - 19~~.
~ •'i '
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~ ROGER POITRAS - - - - -
~ tIRCUIT COURT Notary Public
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~ By ~ ~~~-1c~-~~- D.C. My Commissian expires
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(To b~ ~xecut~d in d~plicats and ori~inal fil~d with Cl~rk Grcvit Cour1, and duplicst~ witl~ Tax Ass~ssor.)
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