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Declaration ot Domicile and Citizenship 1~,~3~?~~~
i44258 1 ~3s~~~
TO THE STATE AND COUNTY TAX ASSESSOR, i~
Sl . IUCIE COUNTY, FIORIDA: ~ G~
This is my declaration of Oomicile and Citizenship in the State of Florida that I am fili~g this day in accordance and
in confo~mity with Chapter 222, Section 222.17, Florida Statutes.
Scotch Plains New .Tersey
I was formerly a legal resident of _ . - -
~C;ty) (State)
1060 raritan Road
and 1 resided at _ _ _ _ _ _ . However 1 have changed my domiGile
(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 LUCIE 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 sate of property or business, or relinquishment of employment
: atf former domicile, removal of family to new domicile, purchase of home, etc.)
. F(LED AN EC OED
~ • • ~ 0
FI ' B~~DED 0
- . - ROOK
_ ~ - . - ~ss ~~a4 $ ~ss
. . . ~~~~r,;: - '66 MAR 25 P f . 40 1
" - `j~~- ' - ~4 - .
3~~U ROGEi3 Nt~•i : N;~c
g- res idence ST. LUCtE COUNTYRK
• . .
v, R~G~n •~~~t : ~~ERK FIORIDA
~ ' ~ ~ ST. LUCiE COUNTY.
FLORIDA
FILED AND RECORDED
! IN ' ' ~900K .
~ G?'1•~tL'~~i `''l:; . , .
~ Re-recorded to change last name a~, ~ . ~ !
corrected to be : Lzo jakds APR s ~ ~0 • 38.. ~ - . .
~ 144258- _ _ :~-,~._:~_::~r _ =
G'p ~ ~ ..Vx=~~ _
~ ~RROGEr~ P01'iRAS. CL.ERK~:-~-. 'r~ - ,
~ i ~ '
IF~T. LUCIE COUNTY. - . . .
~ FLO~tI[~A ~ ~ ~
I FURTHER CERTIFY that I will comply with all other requiremenis o a egal ~esidenf ~o# th~.~ Slet~•
I FURTHER CERTIFY that I have no intention to return to my former domic,ile, and I inTend to remain in FORT
~ PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. r
. . ~ ~ l~
~ ~
. ~
~ _ (Name)
. - ,
• . _ - La jor Stejak OJ;
~ . ; ~
~ ' J'. ':1~:' ~ ~ (Address) -
, ~3~~.4.r..ST ~ J~9C .
R.lla¢eMacb~T1a.33452 ~Q~CN
~ Sworn ta and subscribed before me thia $ day of ~rCh , 19 66
~
~ ROGER POITRAS
K CIR IT COURT Notary Public
gy ~ ~.C. My Commission expires
~
~
(To be ~xecuted in dupli e a riginal fi with Clerk Circuit Court, and dupliuts with Tax Ass~ssor.)
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