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Declaration ot Domicile and Citlsenship 1~3843 ~
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TO THE STATE AND COUNTY TAX ASSESSOR, ~
Sl. WCIE COUNTY, FLORIDA:
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This is my declaration of Uomicile and Citizenship in the State of Florida that I am filing this day in accordance and ~
~n conformity with Chapter 222, Section 222.17, Florida Statutes. ~
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I was formerly a legal resident of __ij3m~C~ S LOIIg Island N. Y•_ ~
(City) (State) ~
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9034 176 Street ~
and I resided at However 1 have changed my domirale ~
(Street and Number) ?
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to and am and have been a bona fide reside~t of the 5tate of Florida since _-___zst___. - _ day of ~
t
y 227 Olive Ave. ~
_ ffia 19 and I ~eside at
(Street and Number) ~
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
an3 this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Florida.
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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.)
Establishing residence
F~~ 193g43
ED aND RECORpEO
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~ 1 FURTHER CERTIFY that I will comply with all other requirementa of a legal resident of this State.
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~ I FURTHER ~ERTIFY that I have no intention to return to my former domic~le, and I intend to remain i~ FORT
~ PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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~3 , . (Name
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% William R JenZen
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~ - . ' Evelyn A. Jenzen
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t" ~,'~~vici~ri~f,~p~and subscribed before me this ~5th day of ~aY 19 70
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? ROGER POITRAS
K CIRCUIT OURT Notary Public
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°'``~'~'e' " D.C. My Commission expires
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'y (To bs ~xecuted in duplicate and ori~inal filed with Cl~rk Circuit Courf, and dupliub with Tax Assessor.) i
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