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Declaratio~ ot Domlcile and C1tit~nship
TO THE STATE AND COUNTY TAX ASSESSOR, ~53324 ~
Sl. LUCIE ~OUNTY, FLORIDA:
This is my detlatation of Domicile and Citizenship in the State of florida thst 1 am fitinq this day in aooordants a~d
in conformiy with Chapte~ 222, Section 22Z.17, Florida Statutes.
1 was formerly a legal resident of Brooklvn j~~ ~r~
K~~Y) (Sta»)
and I resided at _ _ 125 B 18th St rtQt However I have than~ed my domidle
(Strnet and Number)
to and am and have been a bona fide resident of the State of Florida since 12 day of
.I~ne 66
- , 19 , and 1 reside at
(Street a umberj
FORT PIERCE, SAINT lUC1E COUNTY, RORlDA
and this statement is to be taken as my declaration of citizenship, actual legal .~esidence and domicile in the State of Horida.
(Insert here any pertine~t fads, such as sale of pro~serty or business, or relinquishment of employment
at former domicile, ~emoval of family to new domicile, purchase of home, etc.)
Esta~lishing residence
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1 RJRTHER CERTIFY that I will oom I with al) other r ui~ements ~
P Y eq of a le~al rea~dent of this State.
I FURTHER CERTIFY that I have no intention to retum to my former domiGle, and I i~tend to remain in FORT
PtERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. ~ ~
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• (Name)
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~o,' ~ .;,i~.Y.~'•`;
`Cs~ Peter B~ LipP
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r'•r~St~`.xi~ ~ ~ ~MW~~s~ .
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. 6wid~jt to and subxribed before me this ~ ay of ~ rt ~ ~ ~ 9~,
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ROGER ~OITRAS . ~
1. . ~
CLERK CIRCUR COURT Notary Public '
NOTARY PUBLIC. STATE o[ FLORIOA at LARGE
BY D.C. My Commission expiresMY COMMISSION EXPIRES SEPT. 15, 1969
(To b~ ~x~cuhd in duplkat~ and o~inal fil~d with Cl~eic CircuN Courf, and duplisat~ with Tax Ats~aor.)
tOQK1~4 PACE~r~I~I~ 4
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