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Decla~ation ot Domicile and Citizenship
14590`7
Tp THE STATE AND COUNTY TAX AS~ESSOR, ,
51. LUCIE ~OUNTY, FLORIDA:
This is my decfaration of Domicile and Citizenship in the State of Florida that I am filing this day in attordence and
~n conformity with Chapter 222, Section 222.17, Florida Statutes.
1 was formerly a legal ~es~de~t of . Hunti~ton___~ New Yp~-k
(Ciry) (State)
and I resided at __.6__piinCEtOt1_Driv_e _ . However I have changcd my domic,~le
(Street and Number) ~
to and am and have been a bona fide resident of the State of Florida since .lst_ day of
-,~une- 19
66 , and I reside at ._~PsO. Box 224,~]en cen Ep,~rh
Indian River~SDrive.•Bden ~
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
and this statement is to be taken as my deciaration of citizenship, actual tegat residence an~ domicile in the State of Florida.
(Insert here any pertinent facts, such as sale of property or business, or ~elinquishment of employment
at former domicile, removal of family to new domicite, purchase of home, etc.)
New Domicile
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I FURTHER CfRTIFY that I will comply with all other requirements of a legal res+dent of this State.
I FURTHER ^,ERTIFY that I have no intention to return to my former domic,ile, and I intend to remain in FORT
PIERC~~:6~A1Ni'fU~IE COUNTY, FLORIDA, permanently.
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~ . ~ ~ ~ - Rudoipb Osterholm
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' Sworn to and subscribed before me ihis 7tb day of June , ~q 66 .
ROGER POITRAS
CIERK CIRCUR [OURT Notary Public
BY . D.C. My Commission expires
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(To b~ ~x~cut~d in dupliute and ori~inal fil~d with Cl~rlc Grwit Court, snd duplicab with Tax Asse~or.)
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