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~ Declaratton ot Domicile and Citisenshi ~~~~3
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a TO THE STATE MID COUNTY TAX ASSESSOR. '
I ST. lUG1E COUWTY. FtORIDA:
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i ~ This is my decla~ation of Domiule a~d Citiunship in ths St~te of Florid~ thst 1 im filicq thi= day In acoordano~ and
~ in oonformity with CFiapiar ZZ2, Section 222.17, florida Statute~.
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~ 1 wss formerly a le~al ~eiident of ~~~d _ 0~lLio
' (Giry) (Stah) ~
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a~d I rsstded at ~524~ ~~it Aoad
Ha~r~v~ 1 hav~ chanpsd m~? domWl~
• (Sheet and NumbK) _ .
~ to ~nd am a~d havs been s bona fids resWent of the StaM of Florkla ~ino~ _15 d~y of
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J~ , 19 63, and 1 ~esids at 1z3 P'laCitt CotII't~ POrt. S~ I.~Cis
' (StroN and Number~ ~
i , l~ORT MERC~, SAINT LUCIE COUNTY, RORlOA ~
~ a~d this statement is to be taken as my declaration of citis~snship, actusl le~aal residenos and domicile in the Sfab of Horidi. '
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, qnsen hero any pertinent fscts, such a: sale of property or business, or reltnquishm~nt of employment
; at former domicile, mmoval of family to new domicile, purchase of homs, etc.) !
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~ Fll~ A~ D RECOQDED ~ 1
- II~_~ R~tord -
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Betablia~ign reaide~ ---B~OK
~ 1964 JaT~ 29 PM 12: 40
tr~f ~a` . . .
; ~ `~!.'~i~"""~~`*~ . ~ R06ER POITRAS. CLERK i~
: ~ ~s;= ~ S LUCIf COU4TY. FIORIDA
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f 1 FURTHHt CERTIFY thst 1 will ister at
roQ my Iocal address wMn ths ~pishation books reopsn, and aornply with
' att othsr roquirements of e legal resWent of this Stata. _
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~ ! FURTHER CERTIFY that i have no intention to return to my former domiUle, and 1 intend to remain in FORT
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PIERCE, SAINT LUCIE COUNTY, fLORiDA, permanently.
, ~`,y,T..':``'`` , . .
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; • s ? ~t; s ! ~ ~ (Nams)
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~ ~ ti _ ; ~ = ~ Joee~h Kalak
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! ' ~..1 `e.....~`O•` (Addr~u)
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~ Sworn to and subsalbsd b~for~ ms thh ~ . d~i'luarir 1~
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ROG~ ~OITRAS
~ CLERK'CIRCWT COURT Notary Publk -
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~ a ac. . My c«~?~~ .x~~ ~ :
R~'RK ~ iAr[65?
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• Re b~ ~c«w~d iw d~peal~ awd ~iai~al At~d wkb Cl~rlc Ciraih and duplk~ whb Tax A~a
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