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Declaration of Domicile and Citizenship
TO THE STATE AND COUNTY TAX ASSES30R~
F't. Peirce COUNTY~ FUOAIDA: ~~~9
This ia my decJaratian o! Domicile and Citisenahip in the State of Florida t}?ut I am tilinQ this day in ~
accordance, and in coniormity with Chapter 222, Section 222.17, Florids Statutea.
I waa formerly a leQal reaident oi__._Irdianapolis,
-7.n~diana--- -
-
( q?) (3tat~)
and I r~eaided at_. 2924._ Cameron St. However~ I have ctwn~ed my ~lomicile
t3traet aAd Nnmb~r) ~
to and am a~d hsve been • bona tide reaident of the State of Florida since_______________1 dsy of
-------------September 19 . and I reaide •t..__ 9_._Cordova _ St.
Port St. Lucie Ft. Peirce ~8~t ana xume.r~
.__._____.__.._.~..._~__._County, Flot^ida, '
and this etatement ia to be t~lcen aa my declaration of citizenship. aetual leQal reaidence and domicile in
the State of Florida.
(Insert bare an~? pertia~at facta. sueh a~ ul~ oi~ propertY or bwiness. or relinpuW?mait ot uqplorn~at ~t
tora?er Aomicil~. s~mor~l ot lam117 to n~w domieili. Annha~ ot bom~. ~tc)
t My legal residence and domicile ia at 9 Cordova St., Port
3~~ Lucie, Fla.
(2) I am absent from my residence solely due to milltary orders
directing me to rema~n in Kansas. ~
(3) When my tour of duty ir the Air Force is completed, it is
my inteatior~ to reaide and domicile perananently in the state of
Florida. ~ -
C E R T I F I C A T E
I hereby certify that the official military per~onnel reeords of
Cap~ain Jerry i.ee Carroll, 317-k2-5772, reflect the state of
Florida as his state of legal domicile.
f~LEO ~`19 RECCe~DED
1 " c_->-`~ ~ 5. WCIE C0~lNtY FIA.
~jl . • ROGF,: an~sRds ~
~,e ~ CIEFK t;T
~ : . ~ L. ncrno.• ~ : ~
`~LYNN M. kARTIN, 1sL Lt, "US~F
~.~~o~s cus~~~ ,?~i 11 1 34 PN I C
313th Cmbt Spt Gp ( DPM.S ) .
'r'orbes hFB, Kansas 66620 2~12~9
I FUFtTHEK CEBTIFY that I will reQiater at my loca) addreaa when the re~Ltration books reopen,
and comply witb all other requirementa of A le~al raident of thia 3tate.
I FURTBEIt CEFiTIFY tl~at I have no intention to return to my former domicile. and I intend to remain
in~_.__~s2r_C_~.J.~S~e _ ~ Fort Pierce ~~u~~.
. (Cib) '
~2:."11AP.1]L~j1. Jerry L. Carroll , v`~°
i~~ "
(Naim~) ~
__57 N ga or o ekai KS. 66619
,r,~ t~aa~.~ ~
Sw tt~• aubscribed before me thie~~~__day oi
0~~~:~ Please reply to;
, - A. D.19.~
~ Jerry L. Carrol l
Oj ~ 57 N Baylor ST.
~ _ _~~M Topeka, Kansas 66619
blie 8tat~ ot s~ - _
~ m` i+i irea.._~ Co~ission f~tpires Mer 17.1li13
~ ~
f Ottr~• u•eut.d is dn~lk.a and aisln~l N.d wit~ p.:ic Cireait Coort. a.d dnvlkaa with Tuc A..w~or)
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