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IU itit ~ii~it Ai~3D C.i~iji~i'i Tian r'~SSESSOR, .1 1_Cj ~.fG+ ~
Sl. LUCIE C~UNTY, FLOttIDA: ~
This is my declaration of Domicile ~nci Citizenship in the State of Florida that I a?n filing this day in accordance and
in conformity with Chapter 222, Section 222.17, Florida Statutes.
I~..ae fnrmnrlv a Ic+nal r~cir~ant nf Vero BeaCll-_ k1Q.r1d1----_
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(C.ity) (State) ~
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and I resided at 2143 O~ d DiXie ROad _ _ . However I have changed my domi~ile ~
(Street and Number) ~
to and am and have been a bona fide resident of the State of Florida since 1S~ day of ~
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November b5 1923 koval Park Rd So ~each '
- - - i 4--- , and I reside at - - - •
(Street and Number) ~
FORT PtERCE, SAINT LUG1E COUNTY, Fl.ORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in ihe State of Florida. ~
(Insert here ar~ ertinent facts, such as sale of property or business, or relinquishment of emplayment ~
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at former domicile, removal of family to new domicile, purchase of h~~me, etc.)
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Establishin~; residence » ~
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; I FURTHER CERTIFY that I will comply with all other req~irements of a legal resident of this State. ~
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I FURTHER CERTIFY that I have no intention to return to my former domi~ile, and I intend to remain in FORT ~
PIERC~,:SA~~IT•LUCIE COUNTY, FLORIDA, permanently. ~
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. . . ' , X ~a[~c-~-6L ;
, Name) `w ~
~ - Henry enken ~
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" . ~ Ange~-e Henken ~
~ - 6th Jan 66 ±
Sworn to and subscribed before me this day of , 19 .
RQGER POITRAS
RK CIRCUIT C RT Notary Public
~c~l~-c-C~
D.C. My Commission expires
(To be execut~d in duplicate and original filed with Clerk Circuit Court, and duplicate with Tax Assessor.) ~
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