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Decia~atio~ of Dornicila a~d Citize~ship
1515~~
TO THE STATE AND COUNTY- TAX ASSESSOR, - '
Sl. IUCIE ~OUNTY, FLORIDA:
9-
This is my declaration of Oomicile and Citizenship in the Stste of Florida that 1 am filing this day in accordanos ar~d
in oo~formity with Chapte~ 222, Section 222.17, Florida Statutes. ~ ~
. I was forme~ly a legal resident of ~tlanta Georgia
. - (Ciy) (Statel
ar~d ~ res~ded ar _1206 Peachtree Street N. _ S~ _ , Hovrever 1 hsve charpsd my domiCile
~ (Siraef and Number)
to and am and have been a bo~a fide ~esident of the State of Florida since 26th day of
OCtO~ei , ~q 66 , a~ ~ at ~06~ Sotth 10th CtrPpt
• (Street and Number)
FORT MERCE, SAINT LUCIE COVNTY, FIORIDA-f
and this statement is to be taken as my declaration of citizenship, ectual legal residence and domicile in the State of Horida.
(Inse~t he~e any peninent facts, such as sale of propery or busineu, or relinquishment of employment
at former" dom
cile, removal of family to new domicile, purchase of home, etc.)
HOMfiSTBAD PURPOSBS
f AN8 REC
8T• LUC~E C0~ ORD D.
- • RECORp yER
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RK CIRCU~T COURT
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I FURTHER CERTIFY ihat I will oomply with all other requirements of a leya) resident of thi: State.
I FURTHER CERTIFY that I have no intention to retum to my former domiGle, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FIORIDA, permanently. - .
_ . ~ ~`a~-~
~~~,•~~'~,U1:~.. ~ ~ (Name) Brnest . Goldston
• -
V~;,SVU::~ -
; : ~ r ~ ; ' ~ : ~ . 3061 S. lOth Street , Ft. Pierce, Fla.
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~ s ~'v a : ~ " (Addtess)
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! ' • ~ 5th anuar 66
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,'~;;~~$Bv'~cj~i'"feaqr~~suibed before me this day of . 19 . ~
t~~a~~: .
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a • - t
ROGER PORRAS
CLERK CIRCU RT Notary Public
. -
gy 0.~. My Commission expires
(To b~ uc~cuf~d in dupliub and ori~inal fil~d with qKk prcuit Court, and duplkah wiN~ Tax A~or.)
g~K~6~ ~ 16?.
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