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Declaration ot Domicile and Citi:enship
TO THE STATE AND COUNTY TAX ASSESSOR, ~
~
,
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51 WCIE COUNTY, FLORIDA 21'79'70 ~
This ~s my :~eclaration of Domiule and Cihzenship in the State of Florida that 1 am fil~ng this day in accordance and
n conformity w~th Chapter 222, Sect~on ?22.17, Florida Statutes
I was formerly a legai resident of YSrIIOri l~-~~- ~Qr~----
(City) (State)
i
and I resided at 13 V311 ~~8 ?~T@~t However 1 have changed my domiGile 4
(Street and Number)
ro and am and have been a bona fide resident of the State of Florida since 1 st . - day of
October 71 6~1 S. Ocean ~c.
- - . 19_ , and I reside at . - -
(Street and Number)
FORT PIERCE, SAINT IUCIE COUNTY, FIORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Florida.
(lnsert here any pert~nent facts, such ~s sale of property or busi~ess, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
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~ I o4m a foiir ~ar.~ily aparti:~ent house anc. :i two fa~ily t.ouse in
~ fernon, I:ew York. I tlso o:vn a six unit efficicncy at 601 S. Ocean 11r.
; I~m not em~lo~-ed a.t anythin~ other t~i~n cleaning and f ixing thin~s
~ on ~ property. ? have no :~ther relatives here, but r.~y wife.
- ~S,y f our ci~iildren ~nd f ormer wif e, are residt nts of lvew York State
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I FURTHER CERTIFY that I will comply with all other requirements of a legal resident of this State.
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! FURTNER CERTIFY that I have no intention to retum to my former domi~ile, and I intend to remain in FORT
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` PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. '
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( me)
;=1 Cfi~sfFa ` SAN e w SKi
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- (Address)
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Sworn to and subsu~bed beforc me ih;s _ L.~_____ day of - , 19~. ~
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,
ROGER PORkAS ~ "
- CLERK CIRCUIT COURT Notary Public ~
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gy _ } D.C. My Commission expires
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- (To be sxsculed i~ ituplicate and original filed with Clerk Circuit Court, and duplicsts with T~x Ass~s~or.)
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