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Declaration ot Domicile a~d Citizen~hip 222,798
TO THE STATE ANO COUNTY TAX ASSESSOR,
51. lUC1E COUNTY, FIORIDA: .
This is my declaration of Domicile and Citi2enship in the State of Florida that I am filing this day in accordance and
,n conformity with Chapter 222, Section 222.17, Florida Statutes.
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1 was formerly a legal resident of _ ~ _ _ - _
(C ) ~ (State)
and 1 resided at _ __-~~!~u _ Nowever I have changed my domic.ile
(Street and Number)
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to and am and have been a bona tide resident of the Sta/e of Florida since _ ~ s_ day of
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~+N:~f~{1L% 197~_ , and I reside at -CP----- ~42[/ aC//~t~~.
~ Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Florida.
(Insert here any pertinent 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.)
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fi~f0 ANe ~ECORDEO
sT, IUCI[ COUNTP f~~,
ROCFR PQ~TRA
ClE ~K C;~GUIt
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~ I FURTHER CERTIFY that I will comply with all other requiremenis of a legal resident of this State.
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~ I FURTHER CERTIFY that I have no intention to return to my former domicjle, and 1 intend to remain in FORT
~ PIERCE, SAINT LUCIE COUNTY, FIORIDA, permanently.
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~ r ~Q~; ~ (Name)
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. olger E. Petersen
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8n~rotc~.to~d subscribed before me this - day o ~~~`--a~~ , 19~Z
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RGGER POITitAS - ~
K CIRCUIT COURT Notary Public ;
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By D.C. My Commission expires ~
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(To be executed in dupliute and originsl filed with G~rk Circuit Court, and duplicate with Tax Assessor.) ~
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~ooK199 ~cE 39 ~
~;1 No. 13