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~aclAration ot Domicil~ and Citizenship
15:L"738
TO THE STATE AND COUNTY TAX ASSESSOR,
Sl. LUCIE COUNTY, FLORIDA:
This is my declaration of Oomicile and Citizenship in tfie State of Florida that t am filinq this day in acoordanos and
in oonformity with Chapb~ 22?, Sectlon 222.17, Florida Ststutes.
I was forme~ly a leqal rasident of New Yor1c City Nttv Yoik
~ (Ciy~ (State)
and~l ~esided at 18 Stuivesant Oval , Flowever 1 have chenped my domWle
~ (Straet a~d Number)
ro and am and have baen a bona fide ~esident of ihe Stats of Fiorida since day of
February ~ 61 1701 Sunrise Bivd
, 19 , and 1 reside at
(Street and Number)
fORT r1~CE, S~AINT LUCIE COUNTY, RORtDA .
and this statement is to be take~ as my declaration of citizenship, actual legai residence and domidle in ths State of Horida.
(Insert he~e any pe~tinent facts, such as sale of propery or bu:iness, or relinquishment of employme~t
at former domicile, removal of family to new domicile, purchase of FwR~e, etc.)
~stablishing residence ~
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i FURTHER CHtTIFY that 1 will compiy with all other requirerr~is of a lepsl rosident of thb State.
1 FURTHER CERTIFY that I have no intention b retum to my former domicjle, and t intend to remain in FORT
PIERCE. SAINT LUCIE COUNTY, FLORIDA, pe~manently. - ~ f
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~y~qCribed before me this 9 day of _T~nuary , 19~~
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ItO~"rOtr~ws
CLERI( IT Cpt1RT Notary Public
gy ~ D.C. My Commission expires
(To b~ ~aacul~d ie dupliuh and oei~inal Al~d whb Ci~ek Cira~it Couet, and duptie~ wilh Tax Asawor.)
~o~K164 ~ 362
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