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24'7`736
Deciaration of Domicile and Citizenship
~!'U TNt= STATE ANU COUNTY TAX ASSESSOR,
St ,L~~~~-_ ('OUNTY. FLORIDA: "
Tiiis is my dcrlarati~~n of Domicile and Citizcnship in the State of Florida that I am filing this day in
:icror~anc~, :~nd in conformity with Sertion ~"_.17, Florida Statut~s.
I was i'orn~erly a legal resident ot~ --~~bany----- ..-_C~e~------ and 1
(City) (State)
r~sidrd at ~ Q18 _Ele~enth_Ave. _ _ _ _ _ . Howcver, I have changed my domicile to
(Street and Number)
and am and havr bcen a bona fide resident oC the Stat~ of Florida since ~-11f.h___ day. of ~
- . • 19-~---• and 1 n:sidr at _ _
:1222 Ormond Ave.
(Strcet and Number)
- Fgrt Pierce _ - , ~ - County. Florida,
(cit.• )
.,;~d this statement is to be taken as m~~ declaration of citizenship, actual legal residence and domicile in the State ;
ut Florida.
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(Insen here am• pertinent fa~ts, such as salr uf property or Ausinrss, or rrlinyuisAment of rmployment at former
domicile, removal of family lo new domicilr, purchasr of home, rtc.)
Mrnred family to ne* domicile Z2-7-~2
Emnloyed at Dickerson~ Inc.~ Stuart~ Fla. 12-~~-72
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fILEO A~~ RECOAOEO i
ST- ROGf Ht?~ ~RAS`~ ~
• CtEnr :.~~~;;~IT COURT ~ ;
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~ 1 FURTHER CERTIFY that I will re~ister at my local addnss whcn the registration books reopen. and
d ~umply with all other requirements of a le~~l resident of this State. j
,
~ 1 FURTHF.R CERTIFY that 1 ha~•e no intention to return to ~y fornier domicile, and I intend to remain in ~
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y
ti - •
~ - - - - _ - - - - - - - - - • . County,
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: E=lorid~. ~~rmanently- D
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_ ~ RILLIA~_I~._SzRI~~4'!~ - -
= (Name) ~
,
1222 ~raQn_d__gve., Ft. Pierce~_Fla.L331~50
~ ~ (Address) '
S~ti-urn to ~nd subsrribed before me this ~s5 d.i)' of
: ~ _
- ~rn ~~,c-- - - - A . 19~`~_ _ _ . ' ;
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~ Notan PuMic State f Elorida a1 . ` ;
~ ~otery Pub1lc. Sta F7orids at Large i
~fy Commission c~pires _~mm+as:on Exqres .luty lo, 197b _ ~ . ; ~ ;
~ oy-Tranzattti~c~-rnsu~ance co,. . ~ ;
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(Tu br r~rcuted in dupli~air anJ uriK~n:t) (iled ~+'ith ('lerk ('ircuil Coi1t1, and duptieate•Nith Tac Assrcwrl
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