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~ TO THE STATE AND C(~UNTY TAX ASSESSOR,
S1. LUCIE Cc~UNTY, flORiaA: ' '
- This is my declaration of [}omicile and Citlaenship in the Stete of Florida thoi I am filing this c9ay in aaordance end .
in conformity with~Chapter 222, Section 222.17, Florida Statute:.
• 1 ai ~asident of ~O ~
1 was fo~me~ly A eg (State)
(City)
• ~D ~..3 ~ . Howaver I have changed my domidie
and i tesided et ~ -
(Street bnd Number)
n fide iesident of the State of Florida•since ~~s1 day of
ta and am and hava been a ba a
• , L - ,8a ~
_ , 191.~~ and I reside at
~ (Street and Number)
FORT !'iERCE, SAIN= LUCIE COUNTY, FIORIDA "
~ •
~ anci this staternent ia to be taken as my daciaration of c(tizanship, actual iega! residence and domlclle in tF» Stat• of Horlda.
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(insert here any pertinent fads, such as sale of property or businass, or relinquishment of employment
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~ at former domicila, removal of family to nevv domicile, purchase of home, etc.)
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~ ~ . - ~ ~ 9: 45 - ~'J~•`' ~N`~:~~"- r : ~ .
~ , 1964 DEC 2 p . ~
~`~.y:: i .:~j
i ~ r~s ~ ~ ~ •'~a'
_ ~ - . ROGER POITit~A f~lOR~1DA . s
- ST. lUC1E COU~Ij . . _
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i FURTHER C~RTIFY that i will oomply with ait other Pequtremenri of o I~al fssld~l~tt of thl~ Staf~. .
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~ . ~ ,
~ i FURTHER CERTIFY that I have no intention to ~eturn to my former clomidle, and 1 in4end to ~~main in FORT
PIERCE, SAiNT LUCiE COIJNTY, fLORIDl9?, permanently. ` ~ ~
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~ substribed before me this Y ~
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; ~ ClERK CP CU~IT~COURT Notary Publk ~
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~ gy D.C. My Commluion exptra
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~ (To bo ~x~+il~d in d~rpiicah aed ori~iAal fil~d with Chrlc Cireuit Cowf, apd ~pik~ wilb Tax AM~a
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