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Declaratio~ ot Domicile and Citisenship {
~ ~
TO THE STATE AND COUNTY TAX ASSESSOR,
Sl. lUC1E COUNTY, FIORiDA: ~
1
I
This is my declarotion of Oomicile and ~itizenship in the State of Florida that 1 am filing this day in aoo~rdanos a~d i
in oonformiy with Chapte~ 222, Section 222.17, Florida Statutes. , '
~
I was forme~ly a tegal resident of FAIRT~ NBW 1BRS$Y ~
~ (Ciy) (State)
and 1 resided at B07[ lal~ Main $t=e@t . However 1 hsve chsnged my domldie
(Street and Number)
to and am and have been a bona fide resident of the Stste of Florida sinoe ls day of
AuKust , 1969 , ar,d i reside at 103 Gardenia A~e. ;
(Sheet and Number) ;
FORT MERCE, SAINT LUCIE COUNTY, FLORIDA
and this statement is to be taken as my declsration of citizenship, actual lega) residence and domicile in the State of Ho~ida. ;
F
qnsert here any pertinent fsds, such as sale of property or busineu, or relinquishment of employment ~
at former domicile, removal of family to new domicile, purchase of home, etc.)
Homestesd
FILED ANO RECURDEO
S ~ • LUCIE CflUtvTY, F~
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18833'7 ~
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z .^•i~r-.RY, .^.IRCUIT ~^,flU?ZT
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I FURTHER CERTIFY that I will oomply with all other requimments of e Isgal resident of this State.
I FURTHER CERTIFY that I have no intention to retum to my former domicjle, and 1 intend to remain in FORT ~
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. ~
• ~`(~1~' %
N M
~ (Name) ~
~ 103 Gardenia Ave. , Pt. Pierce, Pia.
. . (Address)
=t"'
~ f:` ; .1,4~l,, r 14tb anuar 70 ,
~~y'vpl~n•fdani~•~~s"aibsd before me this day of J 1 , 19
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~ ~U~~~ - Notary Public
~ ~ ~v ~ D.C. My Commi:sion expires
~ BY ,t..
~
_ (To b~ ~x~cuNd in duplicat~ and ori~inal fil~d wifh Clerk Grcuit Court, and duplicat~ wiTh Tax AsNS~or.1
~y 600K1~~ PACE .1~~
s No. 13 . _ . - - - - -
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