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Declaration ot Domicile and Citizenship ~
TO THE STATE AND COUNTY TAX ASSESSOR, 21sJSS j
Sl. IUCIE COUNTY, FIORIDA: ~
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This is my declaration of Domicile and Citizenship in the State of Florida that I am filing this day in accordance and '
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;n conformiYy with Chapter 222, Section 222.17, Florida Statutes. ~
1 was formerly a legal res~dent of FHrID~II~~Ori _ .__-1~S1Ch1gAri -
(Ciry) (State)
and 1 resided at _ 3514~ Freed~m ROSC3 ~~„~ever 1 have changed my domicjle
(Street and Numi~er)
fo and am and have been a bona fide resident of the State of Florida since ~+BT 2bth_ _ day of
,~9_ 69, and I reside ar _ 6901 So_ IndRiver Drive
(Street and Number)
~ORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
and this statement is to be taken as my declaration of utizenship, actual legal ~esidence and domicile in the State of Florida.
(Insert here any pertinent facts, such as sale of property or business, or relinq~ishment of employment ~
a~ former do!nicile, removal of family to new domicile, purchase of home, etc.)
iatabliahing reaidence ST lUC E COUNTY Fi~.
ROCER POITltA: ~
ClEa1~ CiRCU1T COUItT
RECORD YER~FIEO~
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is 3 02 PM •t i ~
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218955 _
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` I FURTHER CERTIFY that I will comply with all other requirements of a legal resident of this State. q
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~ I FURTHER CERTIFY that I have no intention to return to my former domiule, and I intend to remain in FORT ~
e~ PIERCE, SAINT lUC1E COUNTY, FIORIDA, permanemly. a
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' • ~ ~ (Name1 -
~t ~ Harrq E Cross~tt
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. ~ ~ ' ~-f~t~[~i.tL___~ -1~
~ (Addc~O
- ' Arnnina F. Croiaett
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3 16th Ao~ember___ ~q 71
_ Sworn tR,~.wbscribed before me this _ _ _ day of _ _ _ _ ,
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} RO~rER POITRAS
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` ~K GIRCUIT C URT Notary Public
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~ By _ _ D.C. My Commission expires _
~ (To b~ ~xscuttd in dupliuh a~d o~~ins1 fil~d with Cl~rk G~cuit Courf, aed dupliat~ with Tax Ass~swr.)
- C~~~ 1V 1 ~'~r ~ 601
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