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Declaratlo~ ot Domicfle a~d Gitizenship jS~s3 ;
TO THE STATE AND COl1NTY TAX /lS5ES50R,
i
s~. ~uCiE CouNnr, F~oRi~n:
This is my declaration ot Oomic+lc end Citizenship in the Stats of Florid~ that 1 em filin~ this day in aoporda~u and
~n c~nformity with Chspter 222, Section ~22.17, Florida Statutes.
1 was formerly a legal resident of ,L~aCia Ner? Yort
(City) (Sta»)
and 1 resided at _ Z44-67 87 RO~d Howeve?1 havs chan~ed my domic~le
~
(Sireet and Numbe~) i
Novesber 14 1967 !
ro and am and have been a bona f'ide resident of the State of Florids since ~ dsy of #
F
, 19 and I reside at 2826 Oleander Ave.
(Sfreet and Number)
t0ltT PIEftCE, SAINT LUCIE COUNTY, f10RlDA
and this statement is to be taken as my declaration of titizenship, actusl legal re=id~ixe and domicile in the State of Horida.
(Insert here any pertinent facts, such as sale of property or busineu, or rolinquishment of employment
at former domicile, removal of fa:hily to new domicile, purchase of home, etc.) ~
HOI~,STBAD PURFO~SBS
ST`
~UC E CpVECORpEO
•..CO~~ y`R
T~EU~A~
'68 9 p~ ~3363
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! RJRTHER CEitTIFY that I will oomply with all other requirements of a le~al resident of this State.
1 FURTHER CERTIFY that I have no inteniion to reium to my former domicjle, and 1 iniend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
~
' - .
~ t! ~ (Name) ~Ch~ltles B. Moore
. _s
I . , . •i -
`
! . ~ ~ 2826 Oleander Ave.
I - ; - _ -
i€- ~ ` . - ~ G~ _ ~C~fBSS)
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~~/^~1K•~~t~p`'and subsuibed before me this 9th day of Ta~
nuar~? , 19~i$. -
; t 1Li'~,,
i " - - ROGER fOITRAs
CIRCUIT COURT Notary Public
.
8y ~ ~.C. My Commiuion expires
~
F '
j; tTo b~ ~x~auhd in dupljcat~ snd asi~inal f,l~d wilb C1KIc Cira~if Gouh, ~nd a~plicaf~ with Tax AsNaor.)
~~K169 P~284~
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