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Oecla~ation ot Domicil• and Citize~ship j50~~.~Q
.TO THE STATE ANO COUNTY TAX ASSESSOR.
51. U1CIE C:~JUNTY, FLORIDA:
This is my declaratio~ of Domicile and Citizenship in the State of Florida that 1 am fiting this day in aooordanae a~x!
in conformity with Chapter 222, Section 222.17, Florida Statutes.
1 was formerly a legal resident of phi ladel~hia - ~e~a~
(C~h?) ~ ~State)
and 1 rosided at -~~..1~ A? ~r~i-~#tP~t--- Nowever 1 have changed my domidte
(Sireet and Number) -
to and am and hsve been a bona fide ~esider~t of iha State of Florida since 34th ~y ~
NQy~mT~r , t9~i~, and ~ reside ai Grand view Motel No Fed~-at H~r?av
(Street and Numbar)-
FORT PiHtCE, SAiN? LUGIE COUNTY, RORIDA
arxl this statement is to be taken as my declarotion of c~tizenship, actual legal residence and domicile in the State of Horida.
qnsert he~e any pertinent facts, such as sale of properiy or business, or relinquishment of employment
at former domicile, remaval of family to new
domicile, purchase of home, etc.)
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Establishing residence ~,~p ~
6T. dl~E COUN~~
REfORD VERIFf~b
.~so~so
'ss NOV 22 P~y 9 e
- - (
ROGER ~OITR~g i
tIERK CIRCUIT COURT t
I
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I FURTHER CERTIFY that 1 will oomply with all other requirements of a legal resident of this State.
1 FURTHER CERTIFY that I have no int~ntion to retum to my former domitile, and ! intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORiDA, permanently.
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~ K~d~
~~~trir. /L~~-
i~ +
`.Q;~Ut,'~;; ~:UL~ ~ (Name)
' Helen Brams
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%r:-'}" C'.~
,s-' .iY'.r. / C .
_ y~~ ~ - : ; G. .
- ; - - ~ . ; - = ~ _ (Address)
N. ; c,~+ • ' ~ _
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- ~~yQFs?¢an~~trb'scribed k,efore me this 22nd _ day of Novp~her , 19_.b(~.
~ • . . -
~ ROQ~ER POITRAS
CIRCUR URT Notary Public
~ mi i n ex i~es
gy O.C. My Com ss o p
(To b~ ~xscvtM! in duplicab and ori~inal fil~d witb Ctirlc C'iicuH Courf, and duRli~st~ wi11~ Tax A~or.)
aoox 159 ~~E 428 ,
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