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Deciaration of Domicile and Citiienship
~SQ130
TO THE STATE ANU COUNTY TAX ASSESSOR,
St. Lucie _ COUNTY, FLORIDA:
This is my declaration of Domicile and Citizenship in the State of Florida that t am filing this day in
accordance, and in coni'orniity with Section 222.17, Fiorida Statutes. ,
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~ 1 was formerly a legal resident of ~ Ft. Pierce F1Q~ida and I
(citr) " (stace)
n~sidcd at _ 1014 South 12th Street . However, t have changed my domicile to
(Street and Numbe~) -
and am and have bc,•cn a bona fide resident of the State of Florida since 2Sth day of
1955 and t reside at
(Street and Number)
- . - County, Florida,
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and this statement is ta be taken as my declaratiori of citizenship, actual legal residence and domicile in the State
os Florida.
(Inuri here any perlinrnt facts, such as sale of property or business, or relinquishment of employment at tormer
domicile, removai of family to new domicife, purchase of home, ete.)
I was born and raised in Ft. Pier~e, Florida
I am applying for the Sample Scholarship _
25U130
FILEG AMD REC01!pEp
8T. LUCIE COUMTY FLA.
ROCER POtTRA$
CLERK CIRCUIT COURT
RECOR4 VERiFIEO~...~~
M~ut 71 4 0o PH'73
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I FURTHER CERTIFY that I wili register at my local address when the registration books reopen, and
comply with all other requirements of a legal resident of this State.
1 FURTHER CERTIFY that 1 have no intention to return to my former domicile, and I intend to remain in
i Ft. Pierce
Sf . Luc ie County,
Florida, pe~tanently. «'ty> ,
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" Harry dward Lein Jr.
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Sworn to arid~s~rbsciibed before me this ? 1 day of
.•~,~...:;;R~~~ March ~ A.D. 19 73. .
c~-c~lu.~ (D
Notuy Public Shte of FloriJa at Large ^
HOTARY PUB11C, STATE of fLCRIDA a1 (JIRGE .
My Commission expires___~1~~~~rssioN ExF~'~.FS JAN, 15, 1976
~,E 1;. .f tNHITERS
(To be rxecuted in duplicate and origin~l filed with Clerk Circuit Courl, and dupticate with Tax Assessor)
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