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D~Ci~: atit~n ot Jomic:E.: a.:~ ~i:a~~::~:::;~
TO THE STATE AhD COUNTY TAX ASSESSOR.
21'~665
51. LUCIE COUNTY, FIORiDA:
Th~s ~s my deciarahon of Domic~ie and C~t~zensh.p in t^e Jta:e of ~~or,da ::::,i I am f+l~ng this day ~n dCCGfCd(1Cd a;~d
~n conformity with Chapter 222, Section 22:.17, Florida Siatus.~s ~
1 was formerly a lega~ resident of if02't}'1__~81t'
IPOT'e _ Qr11.Q _
(City} (State)
and I resided at lO'~T SOLiLh T8V10Z' However i have changed my ciomi~iie '
f
(Street and Number) ;
to and am and have been a bona fide resident of the State of Florida since __'_~~~Qb~1" _ ~1 _ day of
- - _ _ - _ _ - 1971 and I reside at _ Rt .-_l BOX 6 cj2 B - -
(Street and Number)
Ft ~1 E' ^C@ ~ ~''la •
FORT PlERCE, SAINT LUCfE COUNTY, FLORIDA
~ and this statement is to be taken as my declaration of citizenship, actuat leyal residence and domicile in the State of Florida.
~
~ (Insert here any pertinent facts, such as sa+e of propersy or business, or re+ire,uishment of employment
k at former domicile, removal of family to new domici{e, purchase of home, etc.)
~ Terry Beck, Jr. '
~
Tei'Ty Casdorph f1~E0 ~NO AECOADEO
- it. U1CIE~ COUMT1f FIA.
` ~OGER POlTRRs
~ CLERR CIkCU1T COIIAT t
1tECORO VENIFIED
= OcT 1t 12 ~i PH'T 1
c:
z~
- 21'~665
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t~
- I FURTHER CERTIFY that l w;l! compiy with aIl other requirements of a iegal res~dent o` t'r.is State.
I FURTHcR CERTtFY thas 1 have no insention to return to 'my former dom<<i~e, ar,d ! intend to remain in FORT
= r~iERCE, SAINT l'UCIE COuNTY, FtORIDA, permanentiy.
. r r: ,
1 J `--2-L--- -
_ (Name) Roae ~eck
(Acdress)
-.~i I
- Sworn to and subscr~bed before me inis ~2 - day or _ ~etober _ i9 1
.
= , ~ .
= ROGtR PQ~7hAS: ' -
CLERKCJRC}NT OURf-. Notsry PuS:~c
- ' ' ~ ~
~ By ~ D.C. My Co~nr~~ssion expires _
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' !
' - - -
,'''-_t (To be exeeuted in_duj~Cafa and original filcsd with Clork Circuit Court, and duptitate with Tax Assessar.)
f BOOK 1~7~ PAGr 1 l~2
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