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~ oeciar~tion ot Don~tcil~ and Cftls~~ship ;
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TO TIiE SYATP AND C~OUNTY TAX ASSESSpR, ~
51. lUC1E COIJNTY, FtOR10A: '
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This i: my d~clustior~ of Domicil~ ~nd C1ti~hip in the Stat~ of Florida that 1 am fili~p 1hU da~? i~ aooord~no~ and
in oonformity with Chapt~r ?Z~. S~ctio~ 2~~.17, Fiorkla Statuq~. .
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i wa: iorm.r~y • I.qa~ nsld.nr of ~einon Iadiaaa ~
(Cty) ~Stata ~
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and I nsided at 3a4 lreit 7tL sts!!t ~
(Str~et and Nu~r~b~r)
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ro and ~n and haw baen a bona fid~ r~sidrnt of th~ Staa o# Horida ~i~a lOth ~l ~
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Jnae ~q~ n 121 Ceiestia Cons!
~ l5~«t +~nd Nun~bK)
FORT MER~, SAlNT ~UCIE COUNTY, RORIDA , -
~nd thi~ stat~nsnt is b be tak~ as my ded~r~tior~ of dti~hip. adual lpal naklsna ar~d dornidJ~ in th~ StaN of Hotida.
(Ir?sert h~n any pKtin~nt facri, wch as s~N of prop~rty or buu+wss, or nli~quisl~nNr~t of ~riiplo~y~e
at form~r domidl~, nrnoval ~ family !o ~wv domkib?, purd~as~ of horr~. ~tcJ ~ 1
Bstablishing resid~nce and appi~ing far ho~eatesd
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RECQR~EO; '
' ~ ~ F~~~~AN C~UN?Y. L~'•
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~~R~ ~ERIFIEb
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Zy pN Z : Is
'69 µpR .
~o~E~ ~.o,T ~o~a.~
CLERK CiRCUI?
i FURTHER tERTiFY that 1 will aomp(y with all oth~r nquinrtMnts of a Ipai nsW~nt o~f this Sta».
t FURTHER CERTIFY that I hsve no intentbn to ntum t~ my form~r domicjls, and i intend io remain in FORT
P~, ~ ~lE-COUNT'Y, ftORIDA, p~rmantritiy.
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~ Sw~orn ro~nd wbscr~bd b~ion m~ this a4t~1 ~i~arCL 19 69
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CIRGqT COI~T' No~tary PuWk
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