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• D~~I~ration ot ~omicile and Gilizenship
1'(7 TN~ STATE AND COUNTY TAX ASSESSOR, ~ 1.3~~.(?`~ ~
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Sl. lUCIE COUNTY, FIORIDA;
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This +s my d~clarotion of Domicile and Citixenship in the State of Florida that 1 am filing this day in accardanca and
in conformity with Chapter 222~ Sectian 222.17, Florida Statutes. {
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formerly a legal resident of ____I~L~w R4~ N~--H?-~ Yirg? nia ~
~~;~y~ (State)
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~ , aRd 1 ~eslded a! 941 A~th Street - . Nowever I heve changed my domtcJle
~ (Street and Number)
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b and am and have been a bona fide resident of~he ~Sta1e oi florida sinte ~ 5 - day of ~
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; D~cemUer 64 4305 Metzger Road i
19~~, and 1 reside at
(Street and Number) .
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FORT PfERCE, SAIRIt WCIE COlINTY~ FLORID~ ' . ~
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' and this statement is to be taken as my dectarat+on of citizenship, actuai legal resldence and domicila in the 5tate of Flortda.
' (Insert here eny pertine~t fasts, such as sale of property or business, o~ ~elinquishment of omployment
at former damicile, removat of family to new domicile, purchase of home, etc.)
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i~ t FI~ED A~lD RECORDEO i
j - I~_..~~ic~~~~~.~~~K ,
` ~nterin children i~ 2nd, 3rd and 6th Grades t ~
F .
~ g , , 1964 DEC 3 t Ar? 10: S2 `
; ~ - ' ~ . • ~ SROGER POlTRAS. CLERt(
~ ~ tUCI~ COUNTr, F10RIDA
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I FURTHER CERTiFY tt~at ( wi11 compiy with 811 atF~er reguiremenia of s l~qal rosident of this State.
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1 FURTNER CERTtFY titaP I hava no intention to retum to my former domi~ile, and i intenrl to ram~ln In F~Rt
.s PIERC~, SAINT LUCtE COUNTY, FLORIDA,,pe.tmanently. ~ ~
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E a,...~ . • ~ ' (Name) - }
t~ e . ir„ j~'7•.~ ~ '
v: 1....~ , .n ~ . I
` ~ , Blanche Stacy
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.r. ~ ~'r~ Y - . :
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~ 31 De~ember - 4
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attd subscribed before me this day of , 1~ •
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~ ROGER POIYRAS
• LERK CI UIT COURT Notary Pubtic ~
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gy ~~G~"`-~~ ~ D.C. My Commissian expiros ~ ~
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~ (1'o bs exsc~eted in dupl~ats and arlginal~fited with tiark Grcuit CouN, ~nd dupttcah with Tsx As~e~~or.)
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