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Declaration ot Dorniciie and Cttizenship
TO THE STATE AND COUNTY TAX ASSESSOR,
51. lUC1E COUNTY, FIORIDA: ~
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This is my declaration of ~omicile a~d Citizenship in the State of Florida that 1 am filing this day in accordsnce and
in conformity with Chapter 222, Section 222.17, Floride Statutes.
I was formerly a legal resident of Pittsbur~h Pena. _
~C;~y~ (State)
and I ~es~ded at 830 Stuqvesant Rd. ~yOwevef 1 tlaves C~a~~ my domiti~e
(Street and Number)
to a~d am and have been a bona fide resident of the Stste of Florida` since a?tb day of
_ SeQt_.____ , 19 69 , and 1 ~eside at Rt. 2# Box 2783-A
(Street and Number)
FORT PIERCE, SAiNT LUCIE COUNTY, RORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in ihe State of Horida.
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(Insert here any pertinent facts, such as sale of property or business, or relinquishment of employment ;
at former domicile, removal of family to new domicile, purchase of home, etc.) j
(Hoaestead Bxemption)
RECOR~~~t'~ ~ i
FIl.EO AN ~OUNTY. ~l.A• ~
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i '~0 ~AN s
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R~~,~R i 0?T C~URT,
~LERK CIRCUIT
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1 FURTHER CERTlFY that I will comply with all other requirements of a legal reaident of this State.
I FURTHER CERTIFY that I have no intention to return to my former domicjle, and I intend to ~emain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. G1CD . L1C t
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( ame)
Rt. 2, Box 2783-A
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(Address)
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~ ~ : ~ 21st Januarp 70
Sworn to,~oc~,wbsuibed before me this day of , 19 -
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~ - RQG' . ~~ITRAS
~~~~CI c-'~"~ 1RCUIT CO T Notary Public
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By ~ D.C. My Commission expires
~ (To b~ ~xecu»d in dupfiuh and original filsd with q~rlc Circuh Courf, and dupticah with Tax Ass~s~or.)
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