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. D~claration ef Dvmi~ile ~n~ Citi~eensQ~lp 1;~~(j~ `
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~ TO THE STATE AND COUNTY TAX ASSESSOR,
' ST, IUCiE COUNTY, FIaRIDA: •
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; This is my declaration of pomicile and Citixenship in the Stete of Florida that I am filing this day in ~ccordance and
! in conformity with Cheptet 222, Section 222.17, Florida Statutes. ~
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~ - 1 was formerly a legal resident of «asl1i~i~ton D~C~ .
~ • ~~;y~ (Stete)
~ , and i resided at ~ 6007 7th P1~Ce, N.w. . Nowever I have changed my domtt~le
(Street and Numbar)
b eRd sm and hade been a bona ftde resident of the State af Floridn since Sth day of
:Octobcr 64 . 40QA Avenue P, Suol~nd Garden~
' ~ ~ , 19 , and I re:ide at .
~ ~ (Street ~nd Number)
~ , FORT PIERCE, SAINT LUCIE COUNTY, F10RIDA ~ - . . ~
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and This statemsnt is to be taken as my detlarotian of citizenship, actual legal residonce and domicile in tht ~f~te of Flo~ida.
~ (Insert here any pertinent facts, such as sale of properry or busineas, or relinquishment of amplt~!'Mnt .
at former domicile, removal of family to new domicile, purchase of home, ete.) ' ~
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; . . FIL~D 11~tD RECOftD ` .
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F ~ 1964 DEC 31 AM 10: 52
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} - ~ ~ ~ RoGER poir~zQS. c~F~n . .
~ _ - sr. ~uci~ cour~rr, FIORIDA - - . .
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; i FURTHER CERTIFY that i will comply with at) other requirementa of a lega) rasident af tfita State. ' -
~ i FURTHER CERTIFY that I have no intention ta ratum to my former'domi~lie, and f intend to remain tn FORT
. i-.. PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. ~
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r ~~~!~t.. ~ (Name) ~
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° ~ ' - ~ : fii.,. ~ ;i,T. tq ' ~ ' R~$C Hecht Levin , ~
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~ . . ` ~:i' . (Address) ~ ~ ~
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F + 31 December 64
Sworn to and subscribed before me this day of . , 14
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` ; RO~ER FOtTRAS •
F ~ CLERK CU11 CO RT ~ Notary PublEc ~ _
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k 1 gy ~ D,C. My Commission expl~as
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y ~To b~ ~x~cut~d i~ dupliuts and originai flleil witfi Cierk Cinuit Cou~t, and dvpliuh wlth Tax A~ssor.) .
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