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O~claration ot Domicile ~nd Citisenship
: ~.33120 ;
TO THE STATE AND COUNTY TAX AS.SESSOR, '
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Sl. ltZC1E COUNTY. FIORIDA: . '
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Thi: is my detlar~tion of Oon~icile and Citize~ship i~ the State of Florida that I am filinq thit day in aoootdanos and '
in oonformity with Chapt~? ~22, Ssction 222.17, Florida Ststutes.
I was formerly a le~al rosident of ~ Lf~ke Park ~ ~lorida
(City) (Sta») i .
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3751 Bverglades Road . ~
and 1 rosided at - ~ H~w~vu I have charpsd my domW~~
(Shset and Number) ;
to and am and have been a bona fids rei~de~t of the State of Florida :inos Jinuary day of
~ 202 Southern AveAUe
20 , 19 64, and 1 ~eside at
(Sheet ~nd Number) ~
I~ORT NERCE, SAtNT LUCIE COUNTY, RORIDA
and this statemsnt is ro be taken as my declaratio~ of citizenship, actual le~ai residenos and domkile ln ih~ Stats of Florida.
(insert haro any per~inent facts, such as sale of property or business, or relinquishment of employa?a+t ~
~t former domiciler -emoval of family to new domicile, purchass of home, etc.) ~
1331~0
Bstablishing resideace Fl p~ RE R~~
a1 800K
- " 1965 FEB -5 PM 4: 54 •
' - - ROGER POITRAS. CIERK
$t. LUCIE COUNTI. fl~ DA
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~ 1 FURTHER CERTIFY that 1 will aompty with all othe~ rsquirenwnb of a ip~l raJd~nt of th . Shte~ ~1 ~
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~ i FURTHER CERTIFY that 1 have no intention to retum to my former domitile, and 1 Intad to remilrt-M~"FORT
~ PIERCE~ SAINT LUCIE COUNTY, fLORIDA, permanently. ~
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~ ~leorge J. ~Nickel
~ IJ t~l t ~Q . . UWd~~ss)
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Sworn b~nd wbsa~b~d b~fore me thi: 5 - day of Ptbruitry 19
65
RO~ ~011~11s •
C ~q,1~T Notary Publk
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C. ~ ; My Canrnissbn ~cpt~ ~
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tt. b..oo.a~hi iw a~as.~..~1 ..i~t~al fa.a witl~ a.~k e~a~it c.w+, awd ipNea~. wiN~ T.oc A...M..a
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