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Deciaratio~ ot Domicile a~d Citisenship .
15i52r0
TO THE STATE AND COUNTY TAX ASSESSOR,
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Sl. LUCIE COUNTY, FLORIDA: -
This is my declaration of Domicile and Gitizenship i~ the State of Florida that 1 am filiny this day in accordanoe and
in oonformity with Chapte~ Z?2, Sectio~ 222.17, Flo~ida Statutes.
I was fwme~ly a legal resident of Brightwaters New York
~~ity~ (Stats)
and 1 resided at 473 Ackerson Blvd~ ~Wevef 1 havechanqed my domklle
(Street and Numbe~)
to and am and have been a bona fide resident of the State of Florida si~ce 1St dey of
November , 19 66 , a~ i reside at 380 Ce~estia
(Street and Number)
FORT MERCE, SIUNT LUCIE COUNTY, RORlDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domiule in the State of Horida.
(Insert here any pertinent facts, such as sale of property or business, or relinquishment of employment
at former domicile, removal o~ family to new domicile, purchsse of home, etc.)
FILING FO~R~ HOMEST pt'?RPOSB3
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- RiLED AND R~~~~'
- ST.aECORD VER~E~
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~'61 JAN 3 PM 3: 16
ROGER PQ~TRAS
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1 RJRTHER CfitTIFY that 1 wil) comply with atl other requirements of a(eya~ resident of this Stste.
----1 FURTHER CERTIFY that I have no intention to retum to my former domic,ile, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FIORIDA, permanently.
'/Q~~ _ ~
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~ (Name) -
,,,:t;:,;~::; ALLAN VAN NOSTRAND
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I~v y V"~~~ /
; J~~'' ~ ~Q~~ (Address)
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: '~~t`+ n~„i3.M . .
- : ~ ~ ~ ; = - ~ anuarv , 19 67
;fl ~ Sworn b~si+dsubscribed before me this 3rd day of ~ •
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' I COURT Notary Public 4
c
gy O.C. , My Commiuion expires
(To b~ ~oc in duplicab snd ori~inal Al~d with CIKIc qrwit Cour~, and duplicah with Tax Ass~or.)
g~164 ~ :49
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