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Declaration ot Domicile and Citlzenship ~~~i~~;~~~~
1-~3~3~3()
TO THE STATE AND COUNTY TAX ASSESSOR,
Sl. IUCIE COUNTY, FIORIDA:
This is my declaration of ~omicile and Citizenship in the State of Florida that 1 am filing this day in accordance and
in conformity with Chapter 222, Section 222.17, Florida Statutes.
1 was formerly a legal .eS~de~r of Scotch Plains _ _ New .Tersey _
(Ciry) (State)
1060 raritan Road
and 1 resided at _ _ . _ _ _ _ . . However I have changed my domiCile
(Street and Number)
to and am and have been a bona fide resident of the State of Florida since _ 1_____-_--_-_ day of
September 65 312 Granada Street, Beach
- - _ _ _ _ , 19_-_ and I reside at -
(Street and Number)
FORT PIERCE, SAINT lUC1E COUNTY, FLORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Florida.
(Insert here any pertinent facts, such as sale of property or business, or ~elinquishment of employment ~
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at former domicile, removal of family to new domicile, purchase of home, etc.) ~
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~ FtLED~A~N EC DED ~
~ FI(, . A~ F DcD ''i~fiW18~ a00 -
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I O~ R 0 0 K rt
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. - ~ _ . _ t~ ' '06 f~~R f
- - 4 : ~ f,~.~ , _ , . ` ~ 3._ U56 '
. 66 MAR ZS P I.40
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~ •~~~s'F~~;~~t~g- res idence ~~~~1 ROST Ft : r;::~. CLERK ~
~ ROG~r ~ _ : . :.LERK LUClt C~U~JTY,
f'f~~~ S7. LllClE C~~UNTY, FIORIDA
FLORIDA
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Re-recorded to change last name as - •
corrected to be ~ . Lzo jak ' • ~ ~
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I FURTHER CERTIFY that I will comply with afl other requirements of a legal resident o~ ihrs~ 8iat~• ~
I FURTHER CERTIFY that I have no intention to return to my former domi~ile, and 1 intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. O r
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. . .
~ _ , . : . (Name)
~ ' • -
~ . = Lajor S ojak Lzoja
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Swom to and subscr~bed before me this 8 day of - ~rCh ~ 19 66
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ROGER POITRAS ~
K CIR IT COURT Notary Public t
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gy ~ D.C. My Commission expires
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~ (To bs executed in duplic~e sn~original ~i with Clerk Circuit Court, snd duplicats with Tax Assessor.) z
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