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Oeclaration ot Domicile and Citizenship
TO THE STATE AND COUNTY TAX ASSESSOR,
51. IUCIE COUNTY, FLORIDA: -~"43635 .
This is my deciaration of Oomitile and Citizenship in the State of Florida that I am filing this day in accordante and
in conformity with Chapter 222, Section 222.17, Florida Statutes.
1 was formerly a legal resident of GO~anda_ N@w YOik `
(City) (Stab)
90 North Chapel Street
and 1 resided at - _ - - - - - - . . However I have changed my domicGle
(Sireet and Number)
to a~d am and have been a bona fide resident of the State of Florida since 24 day of
_____November ,~q
6S, and 1 reside at 140 Baton Drive, Port St. Lucie ,
(Street and Number) ;
1
C
FORT PIERCE, SAINT LUCIE COUNTY, RORIDA j
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Horida. 1
(Insert here any pertinent facts, such as sale of propery or business, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
FIL~~~~~
CO OED
--'a~ DOK
. fistablishing residence r£~ ~?+n ~ 7 l~ (t~ ~ 02
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: . ~ . f : - : LUCI~ COUh'TY
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: = F~ORIDA .
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1 FURTHER CERTIFY that I wil) oomply with all other requirementa of a leyal resident of this State.
~ I FURTHER CERTIFY that I have no intention to retum to my former domitile, and 1 intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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E . _ ` ~ . ~ Ward J. White, M.D,
~ - , ~ . (Address)
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~ • J 17 1Narch 66
~ •iSwrdf~t~tti 3r+21,subscribed before me this day of , 19 .
~
~
~ ROGER POITRAS
~ CI IT COURT Notary Public
gy D.C. My Commission expires
~ (To b~ ~x~artsd in duplicat~ and ori~inal fil~d with Cl~lc Grwit Couv1, snd duplicat~ with Tax Ass~sor.)
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