HomeMy WebLinkAbout0543 T' ~
~ciaration ot Dornicile and Citi:enship
15185~
TO TNE STATE AND COUNTY TAX ASSESSOR,
S1. U1CIE COUNTY, FLORI~A:
This is my decla~ation of Domicile and Citizenihip in the State of Florids that 1 am filin~ this day in aooo~danoe and
in oo~formiy with Chapter 222, Section 222.17, Floride Statute:.
1 was forme?ly a legal resident of H~TIN(3TON STATI(~I~ I.ONG ISLAND N. Y.
(Ctry) t~aro)
and I rosided at21 Capital PlaCe .~Howevar 1 hsve cfiarped my domi~3le
(Street and Number)
ro~nci am and have been a bona fide resident of the State of Florida sinoe l8t day of
November 1lt2 ffi~trada ~ve.
, 1~ , and I~ide at ffii
{Straet snd Numbsr)
~ n~, s~?a~ ~uc~ cou~nr, aowow
and this statement is to bs taken as my declaration of citizenship, sctual layal residenoe and domicile in the State of Horida.
pnsert hers any pe~tinent fads, such as sale of property or busineas, or rolinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
FILING IOR IiCMF~TEAD PURPO6E3
RILEO AND RECOAOED ~
ST. ~UCIE COUNTY. FLA. ~
RECOEtD VERIFIED
15185~
'67 ~~',y ~ 3 AM 1u : Z~
I:O:~Ea f'OITRAS
; CLERK CIRCUIT COURT
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I FU~Tt~R CERTIFY that { will oomply witfi all other rsquiremenri of a le~al resident of this State.
1 FURTHER CERTIFY that I have no intention to retum to my former domiale, end I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTIf, FLOR{DA, permsnently.
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u'l
(Name)
.y~.:lNi:!:1)i/~ . r171~i~Vlai+ f+VAl~I . r
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-~~..~.~'~wH~~h G
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.•'rsv~S~ I~,ti.,~j =
f - (Address)
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~ ;~~r~~5worn.to~~l3ubscribed before me this 1~ day of J~~~ , 19~_.
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, Notary Publk
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gy D.C. My Commiuion expires
R. r..~aN~ d~..nd e.idn.t w.d wi* a.~lc cMaih c.~,..wd d~plie~l. wi* Tax A..w.ra
- a~ 164 ~ 541 .
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