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Declaratio~ ot Domlcile and Citizenship
TO THE STATE AND COUNTY TAX ASSESSOR, ;
Sl, IUCIE COUt3TY, FIORIDA:
This is my declaration of Domicile and Citizenship in the State of Florida that 1 am filing this day in acoordance and
in conformity with Chapte~ 222, Section 222.17, Florida Statutes.
I was formerly a legal resident of N@W York _ New York _
(Ciy) (State)
and I resided at 150-20 llth Ave. White StOIIe__Ii. ~pWever I have changed my domic,ile
(Street and Number)
to and am and have been a bona fide reside~t of the State of Florida since ~ 24th day of
_____November , 19 69 , a~ i reside at 2802 Ave. B
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, RORIDA
and this statement is to be taken as my declaration of citizenship, adual legal reside~te and domicile in ihe State of Horida.
(Insert here any pertinent facts, such as sale of property or business, or retinquishment of employment
at former domicile, removal af family to new domicile, purchase of home, ett.)
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(Homestead Exemption)
FtOED ~
FILED AN~ RECO ~
c s. LUCtE COUN?~ E~L'~•
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` C~~RK ~tRrU?T COURT
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~ I FURTHER CERTIFY that I will comply with all other requirements of a la~ai rasident of this State.
I FURTHER CERTIFY that I have no intention to retum to my former domicjle, and I intend to remain in FORT
~ PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. Helen irginia KY'Llg
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~ • - 2802 Ave . B
- . • . ~ I- (Address) •
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Sworn•f~bri~ subscribed before me this 28th day ot January ~ ~q 70
. • • . .
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•,;`,`'Rt~iE~t POITRAS
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- CUIT COURT Notary Public
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YL By D.C. My Gommission expires
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~ (To b~ executad in duplicat~ snd o?i~inal filed witb Cltrk Gnuit Courf, and dupliut~ with Tax Ass~or.)
B~oK1~2 PA~E1543
Ne. 13 ~
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