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Declaration of L3o~tie~Ea~?~~~~~~?~F
`TO THE STATE AND COUNTY TAX ASSESSOR.
3T. L,t7CIE COL'IVTY, FLORIDA:
This is my declaration of I'iomicile and Citizenship in the State of Florida that I am filing this day in accordance
and in confotrnity with Chapter 222, Section 222.17, Florida Statutes.
Roselle Park
I was formerly a legal resident of
[City]
and I resided at 174 +ee3t :want tiil6s _
[Street and Number')
to and am and have been a bona fide resident of the State of Florida since
dew Jersey
-. State
However, I have changed my domicile
31
day of
Jsnuar5 _~ is 62 and I resins at 125 Solz3 z Ave, Port 3t , L.
• [Street and Nurnberl
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA,
and this statement is to be taken as my declaration of citizenship, actual legal residence anj domicile in the State of Florida.
[Insert here any pertine::t facts, su:h as s31~ of property or business, or relinquishment of employment
at former domicile, removal of family to new, domicile parchnse of home, etc,]
Estsblishirg residency
i't FI~D ~q~1~REC D~GOK
1962 DEC I I PI4 I: 41
..;i,:~:ry~;..;'. ROGER POIfiRAS,CIER~~
. -• -G-~ St. LUCIE CnUNfY, FIORID~A~
y:!- ~+~ ~y~f,+Q~`~ ~', Yes
I~ ;
~'r ~ ti c ',f' _
__ ~.,
~ .,,.}~.
I FURTHEFc CERTIFY that I will reenter at my local nddrFSS when the registration b:oks reopen, ar.=t comply
with all other requirements of a legal resident of this States
I FURTHER CERTIFY that I have no intention to return to my former domicile, and I intend to remain in
FvP.T PIERCE., SAINT LUCIE COUNTY, FLORIDA, permanently.
_.. ~
_ [Name]
Peter Bastardi
[Address]
Sworn to and subscribed before me thi: lath lay of DQCetllb8l' 19 b?
ti _
CLERK CIR ' T COL'P.T ~` ~'~~° Notary Pubic
_1___ ~ -.-d....'b+-fi/-~{~~~1SSlon e?Cpile-4
-cY',
{To be execute$ In Gupiicata and origtnat }~
~~_-.~..
;r~:..•a
and dnpllcaSe w1tL 1h~c Assessor]