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Declaration of Domicite and Citizenship
TO THE STATE AND COUNTY TAX ASSESSOR,
Si. lU~~~ COUN7Y, FLORIDA
This ~s my deciaration of Dom~ule and Cit~zensh~p in the S~a~e of Florida that I am filing th~s day in accordance and
~n conformiry w~th Chaprer 222, Section 222.17, Flor~da Statutes.
Nutle~ x. J.
I was forme~ly a legal resident of _ ` -
(City) (State)
21 Revine Ave.
and 1 resided at _ _ _ _ However 1 have changed my domiti~e
(St~t?et and Number)
l~sr~h
ro and am a~d have been a bona fide resident of the State of F{orida since day of
~9
71_, and I~eside ar 1013 SW Coral P.eef yort 5t Lucie
(Street and Numbe~)
FORT PIERCE, SAINT LUCIE COl1NTY, FtORIDA
and this statement is to be taken as my declarat~on of citizenship, actual legal residence and domicile in the State of F{orida.
(l~sert here any pertinent facts, such as sale of property or business, or relinquishment of employment
at former domicile, removal of family to ~ew domicile, purchase of hame, etc.)
Homeatead exemption
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~ 1 FURTHER CERTlFY that I wilf comply with all other ~equirements of a legal resident of ihis State.
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~ I FURTHER CERTIFY that 1 have no intention to ~etum to my former domitile, and I intend to remain in FORT
Y PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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- (Name) C~rlea W. Kucin~ki,Sr.
`s
_ (Add ress)
= Sworn to and subscribed before me this 3 day of De c emb e r 9 71 ~
` ROGER PO,RRA3 ~ :
CLERK GRCUIrt COURT ` Notary Public '
, 1
8y ~ O.C. My Commission expires
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~ (To be executed in duplicate and origina) filed with Clerk Grcuit Court, and duplicate with Tax Assessor.)
_ 19'7 ~i9~96
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