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~ , O~aluatlo~ ot Doml~ll~ aed Cltis~nshq~ . . '~1~~ . - .
TO THE STATE AND COUNTII TAX I?SSESSOR, . ~ ~
ST. 111C1E t'~UNTY, FLORIDA: .
Thi: i: my dscla~ation of Domicil~ and Citi~nd+ip in tht Stat~ of Florida that 1 am filinq this day iq aooordana a~d
in conformiry with Ch~ptsr 222, Ssttion 22Z.17, Florida Statut~t.
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1 wss formesly a Ipal resid~nt of "''~oYo~s P~Y , r+.7a
r Cp~y~ (Stat~)
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snd 1 rosid~d at ~71Q I[aDl• i~~. ~ ~~t. ?O? flow~vK 1 haw du~q«! my danWl~
(Stn~t and NumbK)
ro end am ~nd have bsen a bona fid~ ~sid~nt of tM Stats of Florida sina~ T~ - d~? ~
At 2 Bo: 36a5
Oatob~r , 19,~, ~ i n,~ S~sinol• ~td ~ St. Luoi~
- (:S~e~t and NumbK)
Eo~t s~a~ wc~ cow~nr, ao~w
and thi: statsmem i: to bs taken ss my d~dsration of dtitenship, actual Ipal re~Wsna a~d domkil~ in the Stat~ of HoNdi• -
pnsert t~e any p~rtinsr~t fads. such as sale of prop~rty or busineu, or nlinquisl+msnt of ~nnploym~it
at :.;:-mer domicile, nmoval of family to n~w domidla, purchass of honN, ~tc.)
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~ F~~EO ANO -
Eetabli~hing rseideaae ST• ~UC~~ C0~ ~RO~p ~
RECOR~ VER~EO~'.
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1 FURTHER C'HtTIFY that I will aomply with all oih~r nquinmu~ts of a 1~1 nsid~nt of thb 5tah.
1 FURTHER CHtTIFY thst 1 hsve no intention to retum to my former domidle, and I intend to ramain in FOaT -
PIER~E. SAINT LUCIE COUNTY, FLORIDA, permanenNy. ~
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~,,,l1~.roG ~nd wbscrib~d b~for~ me lhis 17~ ~y ~ OCtob~7~ _ 19 67
ROOlR ~OiTRA~ ~ -
QiR!( CIRqqT Notary Pubik =
g-~~ D C. ~ My Gommissbn ~xpi~
R~ ~~oawwi i~ ~IIcM~ a~ «i~l ~d wid~ CI«k CinrM C~w~, awi drpiica/~ wiN~ Ts~c A~~a
PACE~~ ,
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