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Deciarati~n ~t Demicil~ ~ndl Citiz~r~~h1~
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TiJ 7~tE STATE AND COUNTY TAX ASSESSOR,
Sl. LUCIE COUNTY, ~LORIDA:
This is my declaration of Domicile and Citizenship in the State of Ftorida that I am filing this day in actordance and
• in conformity with Chapter 222, Section 222.17, Florida Statutes.
I was ft~rmerly ~ legal recident nf ~1hanY_---C_ ~~n~erl~nd~ _~_~ib~ ------~~~'~k------
(City) (State) ~
and I resided at N~~y SCOt ldt7d Rd _ . However I have changed my domiCila
(Street and Number)
to and am and have been a bona fide resident of the State of Florida since ls#____ day of
Octobex 65 287~ Merritt Terr.
_ _ . - - - , 19- and I reside at - _
(Streei and Number)
FORT PlERCE, SAINT LUCIE COUNTY, FLORIDA
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and this statement is to be taken as rny decla~ation of citizenship, actual legal residence and domicile in the State of Florida. ~
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(Insert here any pertinent facts, such as sale of property or business, or relinquishment of employment !
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at former domic+le, removal of family to new domicile, purchase of home, etc.) ~ ~
FILING FOR HOMESTEAD PURPOSES , _
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I FURTHER CERTIFY that 1 will comply with all other requirPments of a lega) resident of this State.
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~ i FURTHER CERTIFY that I have no intention to retum t y former domi~ile, and I infend to remain in FORT
; PIER~E; SAIN7 LUUE COUNTY, FLORIDA, permanently.
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f ' ' (Name)
4 . ~ ~-~ti ~ ~ Franklin Beaxdsley
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~ , t;`y'~~~''~ 12tY, January 6b
''Sworn to and subscribed before me this day of , 19 •
1
ROGER POITRAS
LER CI IT COURT Notary Public
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gy D.C. My Commission expires
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(To be execu ed in duplicate and original fited with Clerk Circuit Court, and duplicate with Tsx Assessor.)
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