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STt IUCIE COUMiY. ~A; ,
Declorotion of -Domicile and ~~hzensh~p
TO THE STATE AND COUNTY TA% AS4E.~,SOR;
3T.LIICIE COUNTY. FLORIDA:
This is my declaration of Domicile and Citisenahip in the State of Florida that I am Rling this day in
accordance, and in coi~ormity with Chapter 222, Section 222.17, Florida Statutes.
I was formerly a legal resident of______________ HALTII[OR~ ______--_-_____________-___-- ----___>~A
----'--. -- -t---'---'-----"-'-------
(City) (state)
sad I r~de:3 at-_--. 3028 Northw8~r Dr._ _ However, I have chantted my domicile
(sn~eot sad rinmixrj
to and era and have been shone- Sde resident of the State of Florida since.- -- 15th -__----day of
' r-r-'~
-----------tX:'1Vbltlt- ----- ------- --- ----- 19____0 and I reside at-___.'iGy__ti~_l_i~--bVl3.______R~v'T8__F~F~_______-_____--
(StTeet and Number) ,
FT. PIERCE -------ST•--~FC~----------------------------------- -----County, Florida,
(City)
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in
the State of Florida.
(Insert here any pertinent facts, such as sale of property or ~ or~relinpuisLment of employment at
former domicile, removal of family to new domicile. pnrehate
~.,' ~ 7
9155;
F'..., ,"0 PFCO~?~1E0
;3bi JAN ~ 7 R; ~ ?: ~
~•~-~£R POiTRAS, CLFI::;
S.. LUCIE COUNTY, FLOh!,,A %~~
' •~~~• -
--~ .
- tt{j~~ ~ , f . ,
.~, _, ~
i ~.J ,
I FURTHER CERTIFY that I will register at my local address when the registration hooka reopen,
1aL tt aL ~.. ' a. / 1......, iA.....a / aLS~ Oa~a~
~r~ t n~~~~ vrt~rl 8u u~uca iwuiacauciaw va o icicoa ianauaaa~vi ~aue -~w~,c.
I FURTHER CERTIFY that I have no intention to return to ~- former domicile, and I intend to remain
im -_-__l~,__ ~'~NCE--_-----------_-__-, T..._LIIC.LIE"_---,--------___~____Co,,unty, Florida,
permanently. /'CSao~, .e.,~,c.,,,:9 ,
r
U '~
.-~gta~/a~>~ bafosa ms thia__ 17t1~ of
-:ti '~ • its- (~_ -~~
:~- = : - ~ . A. D. 18_41._.
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a. ,~-._ Ii T1...
-- (Addcwe) ~"---------- -
.Clerk
(To be rs.enaa is dt~lRat~[ad s3.d wk- (a.rt C~eoit court, sad dadiesa wits Tas A.waoz>
Re..n a.ols (~.. )heat Cus. )rfa.