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Declaration ot Domicile and Citizenship ~
TO THE STATE AND COUNTY TAX ASSESSOR,
Sl. lUC1E COUNTY, FIORIDA: , ~~4
This is my declaration of Domicile and Citizenship in the State of Florida that 1 am filing this day in acco~dance and
~n conformiy with Chapter 222, Section 222.17, Florida Statutes.
I was formerly a legal ~esident of -__-~_~_z~°"~
4~+' - A'~y%a."~
(Ciry) (State)
and I resided at _$!t~__~!~ _Yl~_9c~_____-~__ _ However I have changed my domicjle
(Street and Number)
to and am and have been a bona fide resident of the State of Florida since ___.ao~I~ _[6___`___ _ day of
1912.-, and t reside at q~0 Ya Teto
(Street and Number) ~
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FORT PIERCE, SAINT LUCIE COUNTY, RORIDA
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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 facis, such as sale of property or business, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of fiome, etc.)
7o rsy~sTe. c6iYdhe• i,• sc,{oo~C
iT. ~UCIE OOUNTY F~A.
CLERKCCiRr".CUIT COlIRT G
; . REC4R~J VERlF(f0 ,L
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~ 22~04
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~ I FURTHER CERTIFY that 1 will comply with all other requirements of a teyal resident of this State.
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~ I FURTHER CERTIFY that 1 have no intention to return to my former domicjle, and I intend to remain in FORT
~ PIERCE, SAINT lUCIE COUNTY, FLORIDA, permanently.
~ .,,3~~T:±tiir;i=;, ` ~
.c~2. i~.~~~. _ ~WLiif~/Jl.i.[ . 1
~ ; ~~.''~`~Q~i~`'% Re~ ~ R-a--~ ~
' ~ t : (Name)
~ v` Rev. Aaron R. I,avender ~
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~y ~ (Address)
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: Swar~i ~to and subscribed before me this 17xh day of v~+•~~+ , 19~2_.
ROGER POITRAS
='y` K CIRCUIT COURT Notary Public
- gy ~ D.C. My Gommission expires
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(To bo ~xscut~d in dupliut~ snd oripinal fil~d with Cl~rk Circuit Court, and dvplicat~ with Tax Ass~stor.)
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