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t micile a~d Citisanshl 165633 ;
Deciaration o Do p
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TO THE STATE AND COUNTY TAX ASSESSOR, '
Sl, IUCIE COUNTY, FIORIDA:
This is my declarotion of Domicile and Gitizenship in the State of Flo~ida that 1 am filing this day in acoordanoe and
~n oonformity with Chapter 222: Saction 22?.17, Florida Statutes.
I was fo~meriy a legal resident of ~_____Jlllg-S'1' S~D NSW YOR~
~C~y~ (State)
and I resided at - NO ~TRB'HT ADHBSS - However 1 hsve changed my domiti~e
(Street and Numbe~)
to and sm and have been a bona fide resident of the State of Florida since - lst day of
NOVBMBBR ,~q67 , and 1 reside at 2411 ATUNrIC BBACtI ~~V~
(Street and Number) !
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FORT PtERCE, SAINT LUCIE COUNTY, RORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residence ar~ domicile in the State of Florida.
(I~sert here any pertinent fatts, such as sate of property or busineu, or ~elinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
HOMBSTBAD PIIRPOSBS
aE~~~-
ANO ~vN~Y' F~,p.
F~~-EVC~E ~~,c~~Ftcp .
s~ • ~ ~ c 4F ~y
165d Q~ 3
2 .n 7~v'~l
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; ,:,u ~:~r ~CV11 C~v
' c`ERK C
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I RIRTHER CERTIFY that I will aomply with ~01 other requirements of a leya) resident of this State.
I FURTHER CERTIFY that I have no intention to retum to my former domitile, and 1 intend to remain in FORT
PIERCE, SAINTt~I,l,~f'r,I~~COUNTY, FLORIDA, permanently. '
~ ` `r ~c, , _ ~ r___`~C31 ~ ti ~i
Y ~ . . -Jy ~ . WILLIAIrI H. OOBB (Name) 1
~ ` ~ ` ` ~
~ ~ • •U . 2411 ATI~Tr IC BB,ACH BOUIBVARD ~
~ ' ` (Address) ~
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Sworn to and subscribed before me this Z8th day of , 19 68 •
ROGER PORRAS
GRCUIT COURT Notary Public
ay ~.C. My Commission expires
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(To b~ ~x~cuhd in dvplicat~ sed ori~inal fii~d wiTh Cl~rk Cireuh Courf, and duplieatr with Tax Aa~or.1
PooK ~.7~, 366 ~
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