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Declara4ie~n ot Domicil~ anti Citix~nship ;
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TO THE STATE APdD COUNTY TAX ASSESSOR, ~~~~C;
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Sl. IUCIE COUNTY, FLORIDA: '
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This is my declaration of Domicile and CilTzenship in ftie State of Florida that 1 am filing this day in accordance and i
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in conformity with Chapter 222, Section 222.17, Florida Statutes.
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New berry Michigan_____
I was formerly a legal resident of _
(City) (State)
Rural Route #1
and I resided at . . However I have changed my domiCile
(Street and Number)
to and am and have been a bona fide resident of the State of Florida since ___3____ day of
December 54 317 N 12th Street
- - 19--- , and I reside at ~
(Street and Number) +
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FORT PIERCE, SAINT LUCIE COUNTY, FLC~RIDA (
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Florida. i
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(Insert here any pertinent facts, such as sala of property or business, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, eic.)
EstaUlishing residence
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ROGEFt F~OI~~RAS. CLERK ~ - : ~.;•~,i = ' ~
S~. LUCIE COUN7Y. c;' 4...: _ r
F~ORtDA
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~ I FURTHER CERTIFY that I will comply with all other requirements of a legal resident of this State.
I FURTHER CERTIFY that I have no intention to return to my former domi~ile, and I intend to remain in FORT
~ PIERCE, SAIN~ ~:l`JCIE; ~(~JNTY~ FLORIDA, permanently.
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~ , ' ~,y (Name) _
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" ~ . • - ~;~t•. Denzil B. Hetrick ~
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; (Address)
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Sworn to and subscribed before me ihis 2 day of -F~bruary ~ ~q_¢~,
ROGER POITRAS
CLERK CI CUIT ~COU T • Notary :Public
gy ' D.C. My Commissior expires
(To be executed in duplicate and original filod with Clerk Circuit Court, and dupliute wiih Tax Assessor.)
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