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Declaration of Domicile and Citizenship
TO TIiL STATE AND COUNTY TAX ASSESSOR, i~~621 '
~
Zuci~_ COUNTY, FLORIDA:
Tl~is is my drelaration af Domicile and Citizenship in the State of Florida that I am tiling this day in
acror~anrr, and in conl'ormity with Sectian ~'_?.17, Ftorida Statutes.
1 was i'ormerly a legal residrnt of Frede~eiCksburq Virginia and I
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rrsi~ed at _~;4.IlQ]C _`13Q~-------- . However, I have changed my domicile to
(Sirert anJ Numbzr)
~nd am and h~ve becn a bona fide resident of the State of Florida since _ 28th day of
~t?1~~ , l 9_ _?2 and 1 residc at Sunri s e Blvd ~ -
(St~eet and Number)
County, Florida,
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c~nd this statement is to be taken as my declaration of citizenship, ach~al legal residence and domicile in the State
or Florida.
(Insrrt hrrr any prrtinrnt facts, such as sale of proQerty or business, or relinyuichment of employment at fotmer
domicile, removal of family to new domicile, purchue of home, etc.) ~
22s621
Entering c?~:ildren in school
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~ 1 FURTHER CERTIFY that [ will recister at my local address when the registration books reopen, and
~ cvmply with all other requirements of a legal resident of this State.
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~ 1 FURTHER CERTIFY that [ have no intention to return to my _€~mer domicile, and 1 intend to remain in
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s Ft. Pierce St. I,ueie County,
Y Florida, pertnanently. <<~"''~
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R _ . . ` ~ ~ - (Name)
~ ~ - . ~ E~elyn D~aucY ( Yrs Janea )
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; . ~ , (Address)
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$wc~r .'~nc~'subscribed before me this _ 4 th day of
~ ~
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~ - - - April - A.D. 19 72 .
- ~R-~.~,~.e ~v
= Notary Public State of Flonda at l.arge
My Commission expires _ _1S -
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- (To be exrcuted in duplicate anJ oriRinal CJed with Clerk Circuit Court, and duplicate with Tax lssessor) ~
o a z93z .
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