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Oeclaration ot Domicila and Cit • s p
151. ~~~3
TO THE STATE AND GOUNTY TAX ASSESSOR,
Sl. LUCIE COUNTY, FIORIDA:
This is my declaration of Domicile and Citizenship in the State of Florida that I am filinfl.this day i~ eooordsnce a~d
in oonfwmiry with Chapte? 222, Section 222.17, Florida Statutes.
I wss forme~ly a legal ~esident of Port ~efferson N w Ynr~
. iCity) - (Staro)
and 1 ~eaided at 291 Jaytle Hlvd Flcviiever 1 hsve chanyed my domidle
(Street and Numbe~)
S
' to and am and have been a bona fide resident of the State of Fiorida si~oe 1S day of
Augus:: , 19-6b-, and 1 rsside at Route 4 Box 339 -
, (Street and~ Number)
FORT r1ERCE, SAINT LUCIE COUNTY, RORIDA "
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in ihe State of Horida.
(Inse~t here any pertinent fads, such as sale of property or business, or relinquishment of employment
at forme~ domicile, removal of family to new domicile, purchase of home, etc.)
8T~URIE ~p p~ ~ ~
RECORD VERI~
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Bstablishing residence
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55$
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~ 1 R1R7HER CERTIFY that 1 wil) oomply witfi all other requirements of a legal resident of this State.
1 FURTHER CERTIFY that I have no intention to retum to my former domiGle, and I intend to remain in FORT
;
PIERCE, SAINi. ~'~,~,~,z» NTY, FLORIDA, permaner~tly. ~
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~';~:~:~~~•t ; Harvey E. Moser
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Sworn to and subscribed before me this 4- day of JaDUBry ~ 19 67.. .
ROGER POITRAS
CIRC COURT _ Notary Public
gy O.C. My Commission expires
(Te b~ ~oacuhd in duplicsh and oei¢nal Rl~d wifh d~~k qrwit Court, and duplieal~ witb Tax Asat~or.)
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