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Declaration ot Domicile and Citizenship
T ' TAT AND COUNTY TAX ASSES.SOR.
O THE S E
51 IUCIE COUNTY, FIORIDA
Th~s ~s my deciarat~on of Uuni~ule and Citizensh~p in the State of Flonda that 1 am filing this day ~n accordance and
~n conform~ty w~th Chapter 222, Sect~on ??2.17, Florida Statutes
I was formeriy a legal resicient of I•A1~SING ~ 1~ICH• _
(City~ (State)
and 1 rescded at ~ 82's ~sband /~V6. However 1 have changed my do^:;;,ile
(Street and Number)
4
to and am a~d have beerz a bana fide resident of the State of fiorida since 26t~ day of
Sept@mbeT , 19 T~ , and I reside ar `~17 So. 33rd. St.s_.Ft. __Pierea, Fla.
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, Ft0ltIDA
ar.d this statement is ro be taken as my declaration of citizenship, actuat legal residence and dom~cile in the State of Florida.
(Insert here any pertinent facts, such as saie of property or bus~ness, or relinquishment of employment
at former dom+cile, rernoval of family to new domiciie, purchase of home, etc.)
I,ORIE LYNl~ ADKINS 6 y~are of ege
MICHAEL SHAWN ADKINS 3~eara of age .
/tl~-:; `.r:. `LCURQ
f1 l~C;~ ~OUN1Y f~ ~
ae,,tF vo~'~?s ~
RFC~~~YER?F?fO dOU~f
I' OCT ~ 5~ AN ~ t
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1 FURTHER CERTIFY that I will comply with all other requirements of a legal resident of this State.
1 FURTHER CERTIFY tha? I have no ~ntent~on to ret~rn to my former domi~ile, and I intend to remain in FORT
i ,
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. ~j~
lj?~~c..,~~IZ't~~~1' -e'4 GC ~L.2
~ICHAE~_I~F.~_AI?~CI~S_---------- ;
• , (Name)
~
• J
~ y•-' ~ _ 51? So._ 33rd. St._~ Ft._ Pierce, Fle.
~ - ~ ~ z ° . . " (Adciress)
~ _ 334 50
~ ; . :
~ .
•~'•$wom to:attd~~.fi~scr~bed before me th~s 4th day of ~CtObBr _ 19_ 7~
ROGER POITRIlS _ _ - . - - - - -
- LERK CIRCUIT GOURT Notary Public
~ gY _ -__'~-c l../--t.~l Gi-~„~ _ D C My Commission exp:res _ _
~ ,
- - -
(To be sxecuted in duplicate and original filed with C{erk Circuit Court, and duplicats with Tsx Ass~ssor.)
~ R ~,J~ rAG~ JU
B~~~K
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