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De~faration ot Domicil• a~d Citisenshi ~
p 166044
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TO THE STATE AND COUNTY TAX ASSESSOR, ~
Sl. LUCIE ~OUNTY, PlG~RIDA:
This is my decla~ation of Domicite and Citizenship in ths State of Florida that 1 am filing this day in aooordanoe and
~n conformity with Chapter 222, Section ZZ2.17, Florida Statutes.
1 wa: forme~ly a legal ~esident of xew York ~'ity ~sw YorY
(City) (Staro)
and 1 ~esided at ~080 ~?8rk Ave. . However 1 heve chanqed my domi4le
(Straet and Numbe~)
to and am a~d have been a bona fide resident of the State of florida since lgth day ot
- Se=tember , iq~Z., and I reside at 8Q05 So Indian River Drive ~
(Street and Number) j
i
FOltT ~tCF, SAlNt lUC1E COUNTY, RQRIDA
and this statement is to be taken as my declaration of citizenship, actual lega) residence and domicil~ in ihe Stab of Horida.
(inse~t here any pertinent facts, such as sale of prope~ty o? business, or relinquishment of employment
at fornner domicile, ~emoval of famiiy to ~ew domicite, purchase of home, ett.?
~stablishing reoidence F~~EO ANO RECOROEO'
ST, LUCtE COUNTY. FtA.
. • _ Flr „
166Q44 ~ -
'&8 APR 10 ~y 9: 10
. . ~
~:~'~~r; :~o~TRaS
CLERK CIRCUIT COURT
I RIRTHER CHtTIFY that 1 will oomply with all other raquirements of e le~at reaident of this State.
1 FURTHER CERTIFY that I have no intention to retum to my forme? domitile, and I intend to remain in FORT
PiERCE, SAiNT tUCIE COUNTY, FlORIDA, permar~ently.
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~'~wr~,~o and wbsuibsd b~fore rrx this 19th day of APril , 19 6g.
ROGiR ~OITRA:
~ Notsry PuW ic
~Y a'~'~`~'~~ a`~'~~""""~ D.C. My Commission expin~
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