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Declaration ot Domicile and Citizenship ~
TO THE STATE AND COUNTY TAX ASSESSOR,
Sl. IUCIE COllNTY, FIORIDA: •
This is my dectaration of Domicile and Citizenship in the State of Florida that I am filing this day in accordance and
in conformity with Chapter 222, Section 222.17, Flo~ida Statutes.
I was formerly a legal resident of BI'OOic~II BeW YOZ'k _
(City) (State)
816 59th street Kings Co.
and 1 resided at _ _ _ _ _ _ . _ _ _ However 1 have changed my domiGi~e
(Street and Number)
to and am and have been a bona fide resident of the State of Florida si~ce _--___20th _ day of
__~~~embet i9~_, and I reside at 5103 So Ind River Drive
(Street and Number)
fORT Pi6RCf, SAINT tUCIE COUNTY, FLORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Florida.
;
(I,~sert here any pertinent facts, such as sale of property or business, or reli~quishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
i
Establishing residence and applying for homestead
FILED ~PJD RECORDED'
S~. LUCIE CQUtJTY, F~A.
. .'.~i p~J _I~~l=~~Q
i , ~s90~
70 FEB Z PM !2 : I g ~ ;
;
7 (~tTR:,S'" ~
~LERK CIRCUtT COURT
1 FURTHER CERTIFY that I will comply with all other ~equirements of a legal resident of this State.
I FURTHER CERTIFY that I have no intention to return to my former domi[ile, and I intend to remain in FORT
PIER~~~~SAI(~}'i~~~Cl~ COUNTY, FLORiDA, permanently_
- ~UL~I~i; ~ / ~
=J~ . , ~ ~ ~ .
~3 . . . • _ . • , . 3 Z ~
, (Name)
-
, - = r gve G. Olsen ~ ~
~ ~ - :4`~ / '~G~~t7~' -Q~-c~~_
~
. • • ~ lGary A ~O~l~s
en
Sworn to and subscribed before me this 2nd day of February ~ 19 7~
ROGER POITRAS
K CIRCUIT URT Notary Public
,~.~c~~
D.C. My Commission expires
(To be executed in duplicate and original filed with Clerk Circuit Courf, snd duplicsN with Tax Ass~or.)
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gaoK182 PACC~.842
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