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Declaration ot ~omicile a~d Citisenship 14'7'~4'?' i
TO THE STATE AND COUNTY TAX ASSESSOR, ~ ~
Sl , LUCIE COUNTY, FLORI~A:
This is my declaration of Domicile and Citizenship in the State ot Flurida that 1 am filing this day i~ acco~dat~te and ;
~n confo~mity with Chapte~ 222, Sectio~ 222.17, Florida Statutes. ~
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1 was formerly a legal ~es~der~r of Hempstead _~_A_ _ New York _
(Ciy) (State)
339 JerusaZem Ave. ~
and I resided at _ _ _ . ~ ~ _ _ _ However 1 have changed my domitile
(Street and Numbe~)
to and am and have been a bona fide resident of the State of Florida since 6t~~-_ day of
__~une__~____, 19.b6_, anc~l reside a~t 2 BOx 320+B
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, RORIDA
and this statement is to be taken as my declaration of citizenship, actual iegal residerxe and domicile in the State of Florida. ,
(Insert here any pertinent facts, such as sals of property or business, or ~elinquishment of emp!oyment
at former domicite, removal of family to new domicile, purchase of home, etc.)
F«~~ AN~ REGOROEp
Establishing residence ST~ ~UCIE COUNTY. F~,q,
pECORD V~R~F~EO
~ss A~G 2S ~f 1Q : 25
147~~~?
FQ:~Er~, 'r~Ot i R.:j
CLERI( CIRCV~r COURT
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1 FURTHER CERTIFY that t wilt com 1 with all other r virements of a! ~
p y eq egal resident of this State. ~
j I FURTHER CERTIFY that I have no intention to return to my former domic.ile, and I intend to remain in FORt
PtERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
` .'v` ..';i,.~~ ' '~i ~ ~e/'l//'L ~
~ ' ~ "?.~li~IG~~I~ ~~G~~~~
I _ '.C~ - . (Name) ~
, , Wi lia~s G~ Lit+cdholm ~
~ . i _ ~
' - ~
! ~G (Address)
; ~ Grace W. Liadholm
, . % ~ G .
I Au ust
~ Sworn to and subscribed before me this 25th day of g , 19_.ft.6.
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ROGER POITRAS
~ K CIRCUIT C URT Notary Public
I c~l,~.,~.~
~ gY D.C. My Commission expires
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i (To be executad in dupticate and ori9inal ~ilsd with Clerk Grcuit Court, and duplicate with Tax Asses:or.)
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F 8~~~ 153 346 .
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