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Decla~atio~ ot domicil• and Citisenship 1 _
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TO THE STATE AND COUNTY TAX ASSESSOR, t
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51. IUCIE COUNTY, fIORIDA: ~
This is my dec~a~ation of Domicile and Citi=enship in the State of Florida that 1 am filiny this day in scco?dance end ~
~n conformity with Chapte~ 222, Section 222.17. Florids Statutes.
1 was forme~ly a legat ~eside~t of _1~~~~E~'~_______` ' ' -
_ (City) (Stah)
and 1 ~esided at ._~f~._ 1~ _~ie!~O However 1 have changed my domicale ~
~ . s'~treet and Number)
to and am and have been a bone fide rosiclent of the State of Florida since - 7l day of ~
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~ T~- ~'l Bo z.~~ s-- ~.~7'~i~e-cE ~
- - 19---, and I ~eside at ~
(Street and Number) FL/' . '
FORT ~I~RCE, SAINT LUCIE COUNTY, FLORIDA
and this statement is to be take~ as my declarotion of citizenship, actual legal residence and domicile in the State of Horida.
(Inse~t here any pertinent fads, such as sale of properry or busineu, or relinquishme~t of cmployment
at former domicile, ~emoval of family to new domicile, purchase of home, etc.)
?o enrell Children in 3chool ~
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R~. /~y J/~ ,~g ~'L S K/ C' FILED ANO RECaIt0E0
st. wc~E couNTr fui.
ROCER POITRAE "
p~Ea02qN ~o $EL SK/ RECORO vERRF ED~
J~ 8 !I 36 ~M'-TI ~
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I FURTHER'CERTIFY that I will oomply with all other requiremenri of a Ispal resident of this State.
I FURTHER CHtTIFY that I_have no intention to return to my former domicjle, and I intend to remain in FORT
PIERrE, SAINT kUC1E _C~jNTY. FLORIDA, permanently.
. ~ ' . , Jobn Hob~l~lci e
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E p~; ` ~.J ~ 96 Kernochan A~renne, Ae~patead. N. Y.
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Sworn to and s4bscribed before me this 8~ day of ~iT , i9 T~ .
ROGER rO1TRAS -
CiERK CIRCUIT COURT Notary Public
gy _~F-~-~~-1 ~ ~u r ~.C. My Commission expires
(To b~ ~x~cutid ie dupliuN and ari~inal fil~d wilh Cl~elc Gra~it Coue~, and dupliut~ wilh Tax A~o~.) 3
~oe~ 193 ~53
No 13