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• Decla~ation ot Domicil~ and Citizenship ~194
TO THE STATE AND COUNTY TAX ASSESSOR. ~
51. IUCiE COUNTY. FtORiDA: . • . 't
This is my declaration of Uomicite a~d Citize~ship in the State of Fl~ida that 1 am filinq this~day in aaotdsnce a~d
~n m~formity with Chapte~ 222, Section 222.17, Florida Statutes. ;
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1 was formarly a legal resident of -.~eLY4l1~~~S.~C___ ~ New Ycrk
(City) (StaM)
end 1 resided at 1-7 ~_'4'_~ ?th Avellue _~B ~+oOkl Yn) . However 1 have chanQed my domiCi~e ~
;
(Street end Number)
to and am and have been a bona fide ~csident of the State of Florida since _ day of
own roal estate
A~9uSS 19b2---. and I~K11di~ at _Beveriy Street (Block 16771 lot~--- ,
(Street and Number)
FORT MERCE, SAINT LUCIE SOUNTY, RORIOA
and this statement is to be taken as my declaration of citizenship, adual legal residence and domicile in the State of Flo~ida.
(Inserl here any pertinent facts, such as sale af property or business, or relinquishme~t of employment
at famer domicile, removal of family to ~ew domicile, purchase of home, etc.)
I quitted my foRner danlcile of New York ar~d have not subseqwntly resided
the~e~ In fact, 1 have severed every rolati~nshlp - business~ social, and
otharwise - that ! ever had with the State of New York In 1961.
NQ RECON EO ~
f IlEO ~
sj ~UC1f COUNTY ~S
AOCER P0ITRAS G'4
CtfRK ~R
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EO CW~
REC01td ~
MI?~ 13 8 56 ~'11
~3194
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~ 1 RIRTHER CERTIFY tfiat I will oomply with all other requi~emenri of a le~a) resident of this State.
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I FURTHER CERTIFY that I have no inter.tion to return to my former domicjle, and 1 intend to remain in FORT
PiERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
(Name)
nllc hpFL A. /yeli Ko .
o~ IO 1 4~TTAI~t/~1 ~A~/W0~
~ Tl`'~p~~~/ (Address) ~
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~ Sworn to end suburibed beforc rr~ this day of ''•~s •
~ . ~ '+Ol~ ~
~ ROGER ?OITRAS ' ~ ~
r~ CLERK CIRCUIT COURT Notary Publi f,~o ~ ~ ,
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ey D.C. ~ My Commission expires ~~,~ll~~~'~''~TL-3
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(Yo b~ ~x~cvl~d in duplicai~ snd ori~inal fibd witb C{wlc ~irwit Cou~1, and dvplicN~ with Tax Atsu~or.) !
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