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D~laratio~ ot Domtcil~ and Citisenship .
~5~5.~2
TO THE STATE AND COUNTY TAX ASSESSOR, /
S7. lUC1E COUNTY, FlORIOA:
This is my declaration of Domicile and Ctizenship i~ ths State of Florid~ that I am filin~ this day in aaoordanos a~d
in oonformity with Chspter 222, Section 222.17, Florids Statutea.
I was forme~ly a legal ~esidsnt ~~f f alo New Yo rk
(City) (Sta»)
and I ~asidad at 373 H~ntington Ave ~ . However 1 have chanQsd my domivle
(Street and Number)
to and am ar~d hsve been a bona fide resident of tJ~e Stste of Florida since sth day of
i
_ Februsr~? , ~9 67 and I reside at 1$14 North 4Tth strp„p.,~
' (Snaet and Number)
~
FORT ltERCE, 3~IN? LUCIE COUNTY, RORIDA i
. ;
and this statement is to be taken as my declaration of titi2enship, ectval le~el residents and domicile in the Stats of Horida.
qnsen here any pertinent facts, such as sale of properfy or bu:iness, or relinquishment of empioyment ~
at former domicile, removal of family to nsw domicile, purchase of home, etc.)
~ntering Robert in the 5th grade ~
P~t~O AND RECOROEp
" Page in the 3rd grade ~T~ ~UC~~ ~puNTY,
R~GORq V~RIFIED~•
. ~sl FE 15~12
, R 6 p~ 3 7.
=:o::: ~
cIERK ciRC~~ rP~s
i' COURT
1 RIRTHER G'E~tTIFY that ! wlll oomply with all other rsquirements of a lepa) rosident of this State. ~
I FURTHER CERTIFY that I have no intention to retum b my former domicjle, and i intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, fLORIDA, permanently. ~
. - S
~~~~,:~~~,i:trir,~`~ . _
: ~ ~ ~ ~j , ~
= `y~~
~ f~ ~i (Wame) ~
v' • `t~: Margaret Martin ~
_ _ . - 1
~ • • . . (Address) r
'~C, .
'Swvrn to and subs,cribed before me th~s 6 t h day of F P b. q 6 7, i
t
- i
I
_ ,
ROGER rORRAS ~ i
CIRCUIT RT Notary Public
gY °"'E'~''G O.t. My ~ommiuion expi~es
(To b~ ~x~cvl~d te d~plicata aed ari~inal Rl~d with CMrk Ck~ri1 CouK, and duplicah with Tax As~wor.)
d~K164 ~E1526
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