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~ Deciar~tlon ot Domicile ~nd Citizenship '
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TO THE STATE AND COUNTY TAX ASSE5SOR, • ~
. 51. LUCIE COUNTY, FIORIDA: ~ ~ ~
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~ Thls is my declaralion of Domicile and Citizenship in tho Staie of Florida thai I am filing thts day tn aaordance and ?
~ in .conformity with Chepter 222, Ssc?ion 222.17, Florlde Statufea. ~
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~ . ! was formerly a leg~l ~e3ident of West Warren ' ~SSSChUSettS ~
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~ and 1 ~esided at 19 Chapel St . , Howeva~ 1 heve changed rr~y domlr~le
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to and am and have been a bona fida resident of the State of Florida :inte oc tobe r 20 , _~Ay of f
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, 19 6~, and I reside mt 331 501~2 Ave.
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FORT PIERG@, SAlNT WClE COUNTI/, HORIDA ~ •
~ and this atatement is to be taken as my de~:larotion of citizenship, actuel legal residence and domicile tn the Stete af Hotida. ~
(Insert hero any pertinent facts, such as sale of property o~ business, or rellnquishmen~ ot amplo ment
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at former domicile, removal of family to new ~omicile, purchase of home, etc.)
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; Residencq in Ft. Piearcd •
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~i A~Q RECORDEp ~ Q`
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F I ' Pial ~ecord ~OOK , =a` ~
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` ~ 1965 JAN ~4 AM IQ: 39 x ~F^ . - ,
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; ROGER QOITRA ~ ~
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' ST, IUCIE COU!~TY, FlOftIOd a
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` i FURTHER CERTIFY that I wlti comply witfi ali other requlrementa of a(sgal restdent of tht: State.
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~ ~ I FURTHER CERTIFY that I have no Intention to retum to my former damic~la, anai I intend to remaln tR FO~tT ~
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~ PIERCE, SAINT LUCIE COUNTY, FLORIDA, p~rmanently. , i
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~ ~ : ~ ; ~ -y:~ : Marq McKeon '
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Swoth to and subauibed beforo me tt~is 4th day af January ~~9 bS . ;
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' CLLRK ClRCUIT COUR~ Notary Publk
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. - (To b~ ex+cvt~! i~ duplluh aed oripinal Al~d whb Ci~ic Grcuh Co+?r1, a~d deplicM~ wilh Tax A~a ~
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