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D~claration ot Do~icil.e and Citi:~nship ~ ~ ~
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TO THE STATE AND COIJNTY TAX ASSESSOR, ~
Sl. tUCtE COUNTY. FLORIDA: '
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~ Thi= is m~l d~cluation ot Oomkile and Citiun~ip in the State of Florida that 1~m filinp thit day in ~aoordano~ and
. in ao~formiy with ChaptK ~ 2Z2, Ssc?ion 22Z.17. Haida Statutes. :
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i wss formerly a Ipal rosident of ~ Rom~ - ' New Yprk
(City)i (Stat~)
~t 530 South Georpe St. ~ _ t ~~w~~d my domidN
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ro and ~m and haw been a bona fid~ resident of ths State of Florida ~lna 1St ~y ~ ;
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November , 19 64 , ar 1~t07 Bthrens Roxd '
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fORT MQCE, S~AINT LUC~ COYNTY, RORIDA
and this st~tement is to be taken ss my declarotion of citizenship, actual lepal residenos and domicile in ths Shb of Florida. ~
qnsert h~r~ any pert~nsnt facts, such as sale of properry or bu:insu, or rolinquishmer?t of ~mployment :
at former domidle, rsmovai of family to ~ew domicile, purchsse of tame, etc.) `
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Applqing for homestead ~3,?~...c~~ .
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` 1 FURTHER CERTIFY th~t 1 wiil oomply with all othsr requir~b o~f • I~p~l rald~nt of thk Stat~. ~
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E 1 FURTHER CERTIFY that 1 have no intantwn to return to my formsr dank3le, and 1 intend to rem~in in fORT
~ PIERCE, SAINT UKIE COUNTY, FLORIDA, permanently. -
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~ . ~ - v~ ~ e ph P~M1iYowsk3 Sr.
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, 65
:~•~ib~d b~fore me this Sth day of Februttr~ 19_~
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ROa~ r011'~A:
CtRCUIT/~ , f~otary Public .
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D.~. - My C~onwnissfon txpint
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(Te M~oaa~d M dYpNaN a~d ~ei{~al AMd wilb d~i~ .Ci~wiM Gwt, aMl i~lieM~ wilb Taot AM~a . ~
BuR~ ~10 FAfE~JJ ,
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