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~ ~eCl~ration ot Domicit~ and Citisenship 132,~$
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~ TO THE STATE MI~ COUNTY TAX ASSFSSOR, ~
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; ST. LtIC1E COIlNTY, FLORIDA: ~
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; This is iny dedantion of Domidle a~d CiNzanhip In ths Stat~ of florlda that 1 am filin~ thts day (n sooordano~ and ^
+ M conformtty with Chapt~r 2~Z. S~clion 22Z.17, Horid~ Statutu.
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= I was formKly a Ipal ~~id~nt of ' Huntitl~„toD L. I, • New Yer~r
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: a~d t raid~d ~t 29 Pi oe ui~~--~e~a Ebw~vK 1 hav~ ch~nped m1? domld:~
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b and am and h~w b~sn a bon~ Hd~ rotid~nt of th~ Sta» of Fbrid~ slna Tth ~y ~
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Oictobtr 1964 ~ ~_613 So Willows Av~,
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~ I~ORT MlRCE, fA1NT IUCiE COIIMY, fLORqA , ~ (
; a~d 1Ms statarnnt is b bs taken as my deduatbn of dti~hip, actu~l Ipai rKid~no~ and domidl~ in th~ Stat~ af Horida.
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qn~t Mro any psrtinsnt fach, wch as sale of pnopsrry or bv:ineu, or rolirqui~meM oi ~mploym~m--
;j . ~t former domidls, rsnwval of family b new domicits, purdus~ of Iwme, et~cc.)
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~ 8stablishing residenc~ _ ~
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132258 -
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~ CO DED ~
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,~,,'r"rT ,~l"N,,.. 1965 JAN -5 AM l l~ 06 -
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, i~l~~a FtOGER PO~I~TNRY f•~~IQ - ~
.~~.~~,t ; , : $T. LUCIE CO ~
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r FURTHER CERTIFY thN 1 wtll compiy with dl ofhK nqui~b of ~ Ip~J r~id~nt of thb Sht~. ~
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I fURTHER CERTIFY that i hsvs no intention 1o rotum to my formK domicjie, and 1 intend to rem~in i~ FORT .
t PlERCE, SAlNT uJClE COUNTY, fLOR1~A, permansntiy. . -
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