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~ Declaratlo~ ot Domlcile and Citizenship ~
TO THE STATE AND COUNTY TAX ASSESSOR,
Sl. lUC1E GOUNTY, FIORIDA: ~~4~9
This is my declaration of Domicile and Citizenship in the State of Florida that 1 am filing this day in eccordsnte snd '
~n conformity with Chapte~ 222, Section 222.17, Florida Statutes. +
I was formerly a legal resident of Q81StQ_ll~s lTorth Carolina
(City) {Stat~) ~
and 1 resided at __~Q2~ _$Ch0 Zd~e However I have changed my domiCjle
(Street and Number)
to and am and have been a bona fide resident of the State of Florida si~ce 13th day of
__.__$~g~.Q~~Q]~ , 1931 , and I reside at ~nold ROad _
(St~eet and Number)
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA ` a
and this statement is to be taken as my declaration of citizenship, actual legal residente and domitile in the State of Florida,
(Insert he~e any pertine~t facts, such as sale of property or business, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
_
Enteriag c~ildr~a in echool ~ '
8obert Jasos iz 7th grado
3~ Dan in the 12th grnd• ,
F1LE0 Aq~ RECOROEO ~
~ ST.LUCIE COUNTII fLA.
ROCEA PO~~RAS
CLERK CIRCUIT COIIRT
RECORD VER~FIED~
~ SQ 13 10 31 AN'T t
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1 FURTHER CERTIFY that i will oomply with all other ~equirements of a legal resident of this State. ~
I FURTHER CERTIFY that I have no intention to return to my former domi~ile, and I intend to remain in FOkT
PI~RCE, SAINT LUCIE COUNTY; FIORIDA, permanently.
: 4 • t,.
` ' ...i:
(Name)
~ - ~ J o G. Berlow e( Yra llalt~r ) -
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~ . •;.`4 (Address)
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Sworn ta and subscribed before me this ~.jr~ day of 3~jttQlib~T , ~q_,~,
ROGER POITRAS
K CIRCUIT GOURT Notary Public
ey D.C. My Commission exp~res
(To b~ ~xscut~d in dupliut~ and origi~tal fil~d with Clork Grcuit Courf, and dupliut~ wifh Tax Asstswr.)
~o~ly5 ~15~~
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