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O~cla~ation ot Dornicile and Cittzenship
1~~~5
TO TNE STATE AND COUNTY TAX ASSESSOR.
51. lUC1E COUNTY, FlOR1~A:
This is my declarotion eF Oomicile asxl Citizenship i~ the State of Florida that I am filing this day in aceordance and
in oo~formity with Chapte? 22Z, Section 222.17, Florida Statutes. ~
Peeksville N. Y.
1 was forme~ly o legal resident of _
(Ciy) (State)
5 Cross Lane
and 1 resided at However 1 have changed my domicjle
(Street and Numberj - '
ro and am and have been a bana fide resident of the State of Florida since .__-_._29tb day of
rovember , 1966 , and I res~de ar 131 Banyan Dr
(Street and Number)
FORT PtERCE, SAINT LUC16 COUNTY, FLORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Horida.
(Insert here any pertinent fads, such as sale of property or business, or ~eli~quishment of employment i
at former domicile, removal of family to new domicile, purchase of home, etc.) _
FILIIVs FOR HOAiESTE.9D PURPOSES
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~~0 ANO RE~~~~, ~
ST. WCIE COU F
itECORD VEa1F~ED
151~5 . ~ . - .
~i6 DEC 28 P~t 12 • 6 s
i
I~ ROGER PO~TRAS ~
CLERK CIFtCU1T COUtrT ~
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I fURTHER CERTIFY that I will oomply with all other requirements of a legal resident of this State.
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.
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~`~~~1NItltltlpjl~ ame~ i
GV 1T'~L+ ~ii,;-
: .~G PAUL J . PErR.~NB
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_ _ - -~1:~ s~ i ~ ~ (Address) ,
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~ a~•~= tr`.~t.' = 28th December 66 ;
~ ,{~••.;'Svlc~id d1~c}:subscribed before me this day of , 19 . ~
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~ '~''e'r:n:'i'
~ . ROGER PO -
UERK IRC COURT Notary Public
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~ By D.C. My ~ommission expires ~
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(To b~ ~x~aA~d in d~plicsi~ snd osi~insl ~iled with q~rk Cirwit Cou~, snd duplicat~ wi~h Tsx Ast~ssor.)
a~oK 1S2 437
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