HomeMy WebLinkAbout1204 . ~
~
~
, Declaration ot Domicile and Citizenshlp
TO THE STATE ANO COUNTY TAX ASSESSOR,
51. IUCIE COUNTY, FIORI~A:
.
This is my declaration af Uomicile and Citizenship. in the State of Flo~ida that I am filing this day in saordance and
in conformity with Chapter 222, Section Z22.17, Flo~ida Statutes. ~
New York Yew York
I was formerly a legal reside~t of
(C;ty) ~ (State)
and I resided at _ 39-33 49th St. ZOTIg Island ,~Wever I have changed my domicjle '
(Street and Number)
to and am and have been a bona fide resident of the State of Florida since 27th day of
February , ~9 69, and I ~eside ar P• 0. Box ~055 Jensen Beech :
(Street and Number) .i
>
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA ~
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Florida. ~
{
(Insert here any pe~tinent facts, such as sale of property~or business, or relinquishme~t of employme~t ~
,
at former domicile, removal of family to new domicile, purthase of home, etc.) ~
~
~
.
~
(~I~~7~7~17dX~Yf~J~I~
(Establish Residency)
rILED ~-tj0 RECORGED i
;_:!C~:~ r~~F; ~ Y, ~Lr. _
~
~ . ~ . C~
_ .,19083
i
~ 6 ~';~1 ? : 55 ~
f~/~ :
. ; : . - . s :
, i~.....". ~DE1RT `
1 FURTHER CERTIFY that I will oomply vyith all other requirements of a legal'resident of this State.
I FURTHER CERTIFY that 1 have no inteniion to return to my former domicjle, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. aID H Z g
~
(Name)
P. 0. Box 1055 Jensen Beach
(Address)
Sworn to and subscribed before me this day of , 19 .
y,•:,~.
'.t ~
t;;,,stl;1~
_ C~ • ;
•'~tOGER'-~~ ~
3 IRC~l~' GOURT Notary Public
- ' -
~ ' .
' ' r~ .C. My Commission expires
~ -y~. 'N~ •~~Y~~. " . ,
I~ ti
• . ~ _ ~
% ~.~i~i~~~~ ~ . .
, ,•"(To..be ~x~wfed ie duplicate and origin~sl fil witb C it Court, and duplic~t~ with Tax Assessor.) ~
~ BOOK1~~ PAGE~~~~ ~