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j ~ Decla~atio~ ot DornlCile a~d Cittsenship 1~503
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~ ST. UJCIE COUNTY, ROR{DA: •
This is my declaratio~ of Oomicile and Citi~o~nship i~? th~ Stat~ of Florid~ that 1 am filinp this day in ~ooor~da~o~ a~d
in aonformity with Chaptet 224, Settion ~?2.17, Fiorid~ Statutes. .
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I wss formerly a leyal rosident of ~*-'~en _ =IId.
(City) (Sta») ' -
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and 1 rosided at Fbvwver 1 haw cha~~ged y ki
(StreN and Numbsr)
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to and ~m and h~ve bebn a bona fid~ ~ftident of the Stat~ o# Florida sinos d~ ~Y ~ ~
Ooteber ,~9 63 , a~ i r~~ „ 1s08 ~ 87th 8trest
(Street and Numbsr)
l~ORT MERCE, SAINT LUCIE COUNTY. lLORIDA •
and this sfatement is b be taken as my decla~ation of citiztnship, actua! leqsl residenos and domkile in ths Stat~ of Hotida.
qnsert hen any pertinent fads, such a: sale of propsrty or busineu, or rolioquid+ment of employm~nt
at former domidle, nmoval of family to new domicile, purchase of iwrr~, etc.) -
~ ° ~ppl~ing !er ho~ieatead i~5U3
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~ _.,,~,~..~--a ~ , fILED AND RECORDED ~
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~~,-v~~{~ ~ ' '~BOOK ~ -
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''4' J~~ ~i~~' 1964 JAN 21 ' O7
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' ROGER POITRAS. CIERK
~ ~ =~'~~,'~--.s ~ : ~.''~t~ - ST. LUCiF COUNTY. FLORIDA
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~ I FURTHHt CER'TIFY that i will reptster at my bal sddross whsn th~ rpishation books rbopen, ~nd comply with
all otfier requirements of a le~al nsid~nt of this Statt.
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; t FURTHER CERTIFY that i have no i~tention to retum to my formK domidl~, and 1 iM~nd to rematn in FORT
~ PIERCE, SAINT LUCIE COUNTY, FIORIDA, permanently.
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~ Sw~orn b a~d wb~aib~d b~for~ m~ this al • T~IIi~ ~ 19 ~ -
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