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Home My WebLink About2175 p , ~ectar~4ion ot ~ort~i~llg ~nsf Clt~~en~t~l~a ~ ` ~ . YO 1'N~ STAT~ AND ~OUtViY 1'AX ASSESSOR~ -~.i~~,~~.i . Si. tU~i~ C~UNTY~ FIORIDA: . • ~ This is my declaration of pomicile and Cltizenxhip in the S?ate of Florida that I am fllin9 this d~y in acw~dante and . In ro+~fo~mity with Chapter 222~ Section 222.17, Fiartda Statute:. . BrooklyA 34 New '~ork ~ i was formerty a legal rasident af _ ~ (City) (Statej . , snd ! ra:lcl~d e'r 1~36 35th Stx~e 1 . Howevsc~ I hsvs than~ed my domt4ls . (Streat and Numbe~) , Po a~d am ai?d have ba~n a bona fide ~esicfant of the Stats of Floricia sirxe g_.-_ day of O~ tob~r 64 18U B~tp zn Driv~•r _ Pn r 3t _ T.. , 14~`, and I restcie ~t r ..~t-~.-~,C3g ~ (Street and Number) ` fORT MERCE, SAINT LUCi~ COI~NTY~ R~~iDA ~ , ~ _ ~nd this statement is to be taken as my declarotlon of titi:en:htp, acfiuai legal ~e:idence and domicile in the Stah of Florlda. pnsert hera any pertinent facts, such as :ale of property or businesi,•or rolinquisi~ment of emptoyment at former domiclle, removal of family to new domicile, purchase oi home, ett.) . . ~ - . 7'S~ _ ~ . . . . ~ ~ ~~~tfd ANO RE~~~ Bstablishign residence - ~1N ~p . . . ~ ~ 1964 ~e.c. BOQj~ . ~ ~ ~ : . • ~21 Ahi1: . _ . ~~cE~ POITRAS ' - ~ ~r. IUCI~ , CI£RK ~ COUNtr, Ft0~I0q ~ E, . _ . _ = .i . ~ r _ . .f• ~ ; '.•~~r . - • ~i. . ,a ~ i . _ ~ i~.~+ ~ ~ . } o" ~ . ' ~ ~t • ~ . ; ? ' "~~M . t. • ~ ; .'~4, ~ , : I . ~ ~s : ~ . . ~ ! FURTHER CERTIFY tt»t 1 wili canply with ell oth~ r0qulremenri of a(eq~l ra{dmnt of i~~i' ~1~~ , ~ - 1~ . ~ - i'-; i FURTHER CERTIFY that 1 have no intention 4o retum ta my forrnsP damir~le, and ! Intend ta remaln in FGRT ~ ROERCE, SAlNT LUCIE COUNTY, fLQRIDA, parmanently. ~ ! - ~ ~ ~ _ 3_ ~ . ~ . ~ ~r -:~..~~..~~a ~ .a~r t . (N8fT10~ ~ t ' , `..~~i , . 4 ~ rf~~~~' 't'heodort J. ~tate~ & Chzrlts States ~ ~ + ' ~ ' ~ i? : ~ ~ ~ , ~ . , ? i • ~ (P?ddre:s) . ,1 1 : ~ , ± ' ' 4 ~ ~,-.~lL.~ t: v : 21 ~ D~c~aber ~ 6~4 ~ •''Sy~arn to and :ubsuibed before me 4hi: dsy of i9 `o~ E.~° . ~ .M . . - ~ t; ~ ~ ~ ~ ROGER ~OITR/1S ~ i ; CIERK i~ COIMT . lVotary Rublk ~ ; ; _ dy D.C.' My Comm)stbn sxpir~ j . , ~ . . ; _ 1 Q~ br ~x+cut~d ia d~pikaa a~d ori~ai ANd wi1M 1~t~C Cir~a~if Co~+rt, snd d~lie~s wille Tax /1~t~a ti ~ ~eoR~ ~Q~ FA ~ ~ _ . ~37'4 . . . . r - . . . . _ . - . !Y ! M.GY{rQ~qg~~pAbM~l~6 . - . ~ _ _ _ Y a . . . ~ ~ _ . . _