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Decla~ation of Domicile and Citizenship '1~95'?'O ;
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TO THE STATE ANO COUNTY TAX ASSESSOR,
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Sl. IUCIE COUNTY, FLORIDA;
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This is my decla~ation of ~omicile and Citizenship in the ~ate of Florida that 1 am filirp this day in scoordanos and
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in confo~mity with Chapte~ 222, Section 222,17, Flo~ida Statutes.
South (31ene Falls, New Ybrk
1 was fo~merly a legal ~esident of 2~
(Gity) (State)
302 liudson Drive ~
and 1 rasided at . However 1 have thanyed my domicGle
(St~eet and Numbe~)
to and am arid have been a bona fide resident of the State of Florida sinoe 318 t day of
July , lq 68, and I reside at 4~6 N~. 4n'..h gtrPet
_ (Street and Number) ~
FORT PIERCE, SAlNT LUCIE COUNTY, FLORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Hotida.
(Inse~t here any pertinent fads, such as sate of properiy or busineu, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.) ;
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enterinU ohildren in sohool and filing residenoy
F~I.ED AND RECORDED
~T. ~-t~C~E C(?UhTY. F~.~.
^..`.~V~a~l~; .
'~8 I~ E«' t 3 AM I Q: 3 3
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CL.~RK CIRCUIT COURT '
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1 FURTHER CERTIFY thst 1 will aomply with all other requirements of a leyal'resident o~- this Stata. ~
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I fURTHER CERTIFl( that i have no intention b return to my former domicjle, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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mQ) OLi?l~ . sTe eYI
(Addres:) 406 ilo. 40th Street ;
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Swori~.to~~~ad+sWoqs~~~6ed 4efor~,me ihis 13 day of Au~uBt ,~9 68 , ~
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Rap~,~lk~1 ~..~~~._o:
~~C.Q1R~~~~. ~ O "s Notsry Public
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BY . " ~ ~ D.C. My Commtuion expins
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' R~ ~w! ~ W' d++p~ and ai~ia~l fiNd wil1~ Ct~ric Grarit CovM, awd d~plicaN whh Tan Ass~a
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