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~e~laration ot Domicile and Citizenship
TO THE STATE ANO COUNTY TAX ASSESSOR,
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51. LUCIE COUNTY, FLORIDA: ~
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This is my declaration of Domicile and Citizenship in the State of Florida that 1 am filing this day in accordance a~d
in conformity with Chapter 222, Section 222.17, Florida Statutes.
Bridgeport Connec4icut '
I was formerly a legal ~esident of -
~C~ty~ (State)
25 Sanford P1aCe 06604 _ However I have chan ed m domitile
and I resided at - - - - - 9 y i
(Street and Number) ~
to and am and have been a bona fide resident of the State of Florida since -~~1~~~3
2-~ day of ~
306 No. 22nd Street `
, 19~~, and 1 reside at - ~
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
and this statement is to be taken as my declaration of citiienship, actual legat residence and domicile in the State of Horida.
(Insert here any pertinent facts, such as sale of properry or business, or relinquishment of employment ;
~
at former domicile, removal of family to new domicile, purchase of home, etc.)
Bstablishing residence with intent to f ile for
homestead exemptioa FILEO ANO RECOROED~
ST. LUCIE COUNTY. FL .
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'69 OEC 17 I :55 ~
18`?'230 ~
~ F~t`i;E~ "rQ! i r~AS
~ CLERK CIRCIlIT COURT'
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1 FURTHER ~ERTIFY that I will oomply with all other requirements of a legal resident of this State. '
I FURTHER CERTIFY that I have no intention to return to my former domiule, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
, A ~
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(Name) r T. JaCtsoD ~
~
~
~ (Address)
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~ S~ldOf~ 1A~.subscribed before me this 17 day of December ~q 69
~ _ , ' '
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~ j ~oc~t fo,uR,e?s:
~ CLERK CIRC8IT LbURT Notary Public
"4` i.
~ gy ' D.C. My Commission expires
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~ (To be ~x~cvMd in dupliute and ori~insl ~ilsd with Clerlc Grcuit Court, and duplicah with Tax Ass~ssor.)
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eoo~ ~81 ~ ~~.99
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