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DeCiaration ot Domicile and Citizenship
TO THE STATE AND COUNTY TAX ASSESSOR,
Sl. LUCIE ~OUNTY, fIORIDA:
This is my declaration of Oomicile and Citizenship in the State of Flo~ida thst 1 am fili~g this day in accordanos and }
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in oonfo~mity with Chapter 222, Section 222.17, Florida Statutes. :
I was formerly a legal resident of - $titten Islaad _ NeM YOr~
(City) (State)
and I resided at _ 1515_ Royal Dt~r! However I have changed my domiCile
(Street and Numbe~) ,
to and am and have been a bona fide resident of the State of Florida si~ce `jV~e la dey of
,~9
69, e~d i reside a~ 161 Princess Drive (port St. Lucie~
(Sireet and Numbet)
fORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
and this statement is to be taken as my declarotion of citizenship, actual legal residence a~d domicile in the State of Horida.
(Insert here any pertine~t facts, such as sale of property or business, or relinquishment of employment
at former domicile, removal of family to ~ew domicile, purchase of home, etc.)
Bntering child in pnblic school -
AndseM Dsna
,
FILEO ANO RECORDED
ST, IUCIE COUNTY. FLA.
F~.1~,~~v~ED
'69 J`J~~ 27 PM !Z : 29
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~ F•1~' "OITRaS
~ CLERK CIRCUIT COURT 1
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I FURTHER CERTIFY that I will comply witfi all other requirements of a leysl resident of thls State.
1 FURTHER CERTIFY that I have no intention to return to my former domicjle, and I iniend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. ~
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~ ; ; .,r ~ ~ Henry Dsna
~ Name .
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~ ,1969
~ S~Mrc~n to ~and subxribed before me this 27th day of Jnne
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ROG~ POITRAS
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~ CLERK CIRtUIT COURT Notary Public '
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~ By D.C. My ~ommission expires
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_ ~To b~ ~x~cui~d in dupliuro snd ori~inal fil~d with G~ic Grcuit Cour1, snd duplicat~ with Tax Aa~ssor.) ~
OR ~
~ ,3 aooR
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