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De~laration ot Do~nicile and Citise~ship
14'7331
TO THE STATE AN~ COUNTY TAX ASSESSOR,
51. LUCIE COUNTY, FIORIDA:
This is my declarotion of Domicile and Citizenship i~ the State of Florida that I am filing this day in atcordante and
in conformity with Chapter 222, Section 222.17, Florida Statutes.
Long Island N Y New York
I was formerly a legal resident of _ _ -
(Ciry) (State)
and I resided at __?~22 Jerusalem Ave. ~ N Kel"Z'iCk However I have changed my domiCi~e
(Street and Numbe~)
to and am and have been a bona fide ~esident of the State of Florida since _._~5~__- day of
, 19 and I reside at _lA7 Indisli Nills Drive
(Street and Number)
fORT PIERCE, SAINT LtJCIE COUNTY, FLORIDA
and this statement is to be taken as my declaration of citizenship, actual lega! residence and domicile in ihe State of Florida.
(Inse~t here any pertinent facts, such as sale of property or business, or ~elinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
~stablishing residence
F~~E~ AND
ST, CU~~F ~
~ ~OROE~
RECORD yFR~F~EO~'
_ ~66_~~.=~Cv ~~yr _
AUG Z ~"`{-cL
14~, 9' ~s
t~,~R Y 332
~~FRK ~~RCUIT ~
URT
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~ I FURTHER CERTIFY that I will oomply with all other requirements of a legal resident of this State.
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~ I FURTHER CERTIFY that 1 have no intention to ~eturn to my former domiCile, and I intend to remain in FORT ~
~ PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. !
~ ~ti,,:~::u~r..
~ • ~ ~ ( ame)
F ; Har Parker
~ • ~ 1 • ~ C'~ ~ ~ • ~ V
~ ~ •
` • . •
. V ~
~ . . . , ' Lillian ~ ~arker
~ " . • , ~ ~
~ ~ SwoM~id~and subscribed before me this 2nd day of ~ugust , 19~L_.
~ -
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~ ROGER POITRAS
CIRCUIT~OURT Notary Public
~ 1~
~ By ~~`-'~'G ~P D.C. My Commission expires
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(To be ~xecuted in dupliut~ and original ~iled with Clark Grcuit Court, snd duplicsM with Tax Assessor.)
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