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oeciaration ot Domtc~~e A~d Citi:enship 15~7,54
TO THE STATE ANO COUNTY TAX ASSESSOR, . ~
S1. IUCIE COUNTY, FIORIDA: . ~
This is my declaration of Oomicile a~d Gitizenship in the State of Florida that 1 am filinq this dey in aooordanos and
in oonformity with Chapter 222, Section 2~2.17, Florida Statutes.
INDIAN RIVBR MICH.
1 was formerly a legal ~esident of
(City) (Stah)
~ Ge n. De 1. . Flcwever I have cha m domiCile
and 1 residad at T ~W~ Y
(Street and Number)
ro a~d am and have been a bona fide ~esident of the State of Florida since 20th day of
OCtOber , 19 66 ~ a~ at 1103 Yor)c Ave. ~
(Street and Numbe?)
FORT MERCE, SAINT LUCIE COUNTY, lLORIDA
and this stateme~t is to be taken as my decla~stion of citizenship, achial legal residence and domicile in fhs State of Horida.
(Insert here any peninent facts, such as sale of property or busineu, or relinquithment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
J
FILING FOR HOMESTBAD PURFOSBS ~
S
.~I~CAE CO~I~tA.
R~CORO VERIFI~O
15i'7S4 ~
'67 JAN 10 AM 10: 0 "
' . n~GEe~ ~ OITRAS
~ CIERK CIRCUIT COURT
~ ~
1 RJRTNER CERTIFY that 1 will oomply with all otF~ raquirements of a legal resident of ffiis Stafs.
' ~
1 FURTHER CERTIFY that ! have no infention to retum to my former domicjle, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
,
.
(Na
`~~~uu~~tt~rrrr~~~~ JOHN A. CZ~jKOWSKI
G~IT EQ jii,~
G~ i,t i~
. ' c~ ;
yv ;,S , C?' ~ (Address)
; r~'~:~d~7:~ ~
: 4 • ~ ~y :
' . S - . = -
^ r~: • =
' ~subsaibed before me this 10 day of Januarq 1967
:
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'•s~: ~
~
~ ~
~ ~ ~ C RT Notary Public
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By D.C. My Commiuion expires
(To b~ ~a~tad in duplicat~ and ori~inal Al~d w8h CIKIc Cira~it Cov~, and dupliuta wH6 Tax A~ao?a
~ 600if 1~ P~CE
~ .
~~x - - -.._._r.