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De~laration of Domicile and Citizenship
TO THE STATE ANp COUNTY TAX ASSESSOR, t~ry+'~~
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51. LUCIE COUNTY, fLORIDA:
This is my declaration of Domicile and Citizenship in the State of Florida that I am fiiing this day in actordance and
in conformity with Chapter 222, Section 222.17, Florida Statutes.
I was formerly a legal resident of NCM_ YOr]C._ C~t.~? _ _
(Ciry) (State)
and I resided at 65~ 14th $t___~Il~.a~_~~IL___ _ However 1 have changed my domic,ile
(Street and Number)
ro and am and have been a bona fide resident of the State of Florida sinte 29t,b . day of
Npvembtt _ 1964 , and I rsside at 1902 Roy~l__Palm 1~~~
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(Street and Number)
FORT PlERCE, SAINT LUCIE COUNTY, FLORIDA
and this statement is to be taken as my declaration of c~tizenship, actual legal residence ano dom;cile in ihe State uf Florida.
(lnsert here any pertinent facts, such as sale of property or business, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of hnme, etcJ
~stsblishing re~idency
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. `~t~ = ~65 ,UL ~ ~ ~
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RpG~~ i'~1~'t:COU~?Y.
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I FURTHER CERTIFY thai I will comply with all othsr requirements of a legal resident of this State.
!~URTHER CERTIFY that I have na intenti~n to return so my former domiLile, anci I intend to remain +n FOR7
PiERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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~2~L~s~~~~_ / ' '~~L~ ~
Gertrude ~~"~~erne ~
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~ . ~ s~eph~ d~i~rney J j1'~'
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: -l~tl1 da ot - 19-65
= _y :~yvorn to and subst~t~ed before me this _ _ y , ,
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. ROGF~ POI'C~1S; -
i~ ~C11tCt11~CAURT Notary Public
g ~~~~G~ O.C. My Commission expires
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(To b~ ~xecutsd in duplieate ~nd originai filed wit#~ Clerk Circuit Court, and ciuplicate wiirh Tax Assessnr.) v
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