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Declaration of Domicile and Citizenship
220362
TO THE STATE AN~ COUNTY TAX ASSESSOR,
Sl. lUC1E COUNTY. FIORiDA:
This is my declarstion of Qomicile and Citizenship i~ tha State of Florida thet 1 am filinfl this day in acco~dance and
~n conformity with Chapter ?22, Section 222.17, Florida Statutes.
I was formerly a legal resident of Rochester _ _ AeR York _
(City) (~t+M)
and 1 resided et _~-1.2 A~ Rzr~nder SttBBt _ Howevsr 1 hav~ changed my domicile
(Street and Numbe~)
to ar?d am end have been a bona fide ~esident of the State-of-FJorida since 7th day of
December 19_~1 and 1 ~eside et 102 Hilton Drive ( Temporarv
(Street a~d N~mber)
FORT PIERCE, SAINT LUCIE COUNTY, fLORIDA -
end this stateme~t is to be tsken as my declarat~on of citizenship, act~el legal residence and domicile in the Staro of Florida.
(Insert here any pe~tinent facts, such as sale of property or busi~eu, or reli~quishment of employment
at former damicile, romoval of family to new domicile, purchase of hom~, etc.)
22036~
Entering children in achool fttf0 ~MO RfCQR~f~
fT. LUCIE COWITY f
~ IIOGER POITR~~
I,elia in the 12th ~rade CLfRK CIRCUIT COIiAT
RECORD VER~FIEO~~
Cooper in the lOth grede
pnnette in the 8th grade DEC {3
, Ricke~ in the 7th grade
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i L~ichael in the 6th grade ~
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; Wiliiem in the 3rd grade
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$
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~ 1 RIRTHER CERTIFY thst I will oomply with al{ other requirem~nts of a leqa) restdent of this State.
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~ 1 FURTHER CERTIFY that I have no intention to return to my former domiGle, and I intend to remain in FORT
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~ PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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~ ~ ~ Charlesetta Jeckaon
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' ' " (Address)
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~ ~~in~~o,and subxribed before me this 13th day of December ~~q 71 ,
- ROGER POlTRAS
CLERK CIRCUIT COURT Notary Public
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~ 8y~~-~- D.C. My Commission expires
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(To b~ ~x~cut~d in dupliut~ and ori~inal ~iled with Cl~irk Grc~it Co~rrt, and dupliut~ with Tax Ass~swr.)
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`'0.~ „ A aooK 197 ~~E 2 l08 -
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