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DeClaration ot Domicfie and Citize~ship ~
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TO THE STATE AND COUNTY TAX ASSESSOR, !
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51. IUCIE COUNTY, FtORIDA: `
F}
This is my declaration of Domicile and Citizenship in the State of Florida thst I am filing this day in accordance and $
~n conformity with Chapter 222, Section 222.17, Flo~ida Statutes.
I was formerly a legal res~de+~t of __GREENUP _ KENTUCKY
~~~ti~ (State)
and I res~ded at US_Hw1 #23 ~ However I have changed my domicjle
(St~eet and Number)
ro and am and have been a bona fide resident of the State of Florida since _____-_____26th _ _ day of
No~eaber , ~9-?~ and I reside at Rt , Ba 11, Cherles Drire
(Sireet and Number) !
FORT ~IERCE, SAINT LUCIE COUNTY, RORIDA
and this statement is to be take~ as my declaration of citizenship, actual legal residence and domicile in the State of Florida.
(I~sert here any pertine~t facts, such as sale of property or business, or relinquishment ot employment ;
t
at forme~ domicile, removal of family to new domicile, purchase of home, etc.)
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RESIDENCE e~fRK
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RECORO VERIf1f0.,~~ j
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~ I RJRTHER CEitTIFY that I will oomply witfi al) other requirements of a le~al resident of this State. ~
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~ I FURTHER CERTIFY that I have no intention to return to my former domiu~e, and I intend to remain in FORT
~ PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. ' ~
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~ xoT i~ns
~ (Name)
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''~r Rt. 1, Boz 1 t, Charles Dri~e, ~'t,
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1 ~ ~ . ~ - (Address) pierce, 1~1n.33450
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~ ' ~ 15th Yareh , t9~?
,Sworn to br~.spFl3cribed before me this day ot
l3 ` ' ~ I~11
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SY . - •
= ROGE~ ~OrtRAS
CIRCUfT COURT Notary Public
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g D.C. My Commission expires
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~ lTo b~ ~xacvt+d in duplicsb am! ori~inai ~il~d with GKk Circuit Court, and duplicsa with Tax Aswssor.)
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