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, Oeala~ation ot D~nlCll• and Gitizenship ;
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TO THE STATE Ah~ C'OtJNTY TiV~ ASSE~SOR, • ~ ~ i
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~ ST. lUC1E tOUMY, RORIDI~ ~ ;
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This i: my d~daratlon of Qpnidl~ and CHiz~nship in tM St~t~ of Horlda that i am fllirq thit day in aooorda~o~ and ~
in aor?tormily with GuptK ~Z~, S~et1o~+ Z'l't.t~, Ffo~ida S~rii?~s. ' . ,
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• ~ ! was famerly a ipal ~id«+t of ~ttstot~ Ne~v ~igr~e _ ~ I
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- and 1 rastdsd at Pittsto~et'~ How~v+r I haw charped my domldl~ _
I Rha~t and Number? i
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~ 1~0 ~f1d ~f11 afld ~1ii/~R ~!R • b01'10 mibAffl Of tjlA St01! Of F~OI~ iTf10! pf ;
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Na~ber t963 and ~~tcl~ n ~.0 ~~irs M
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~ORT M~C~, SAINT LUClE COUNTY, R~ORfDA
and this statane~t is to be tak~n as my ded~refion of dtimn=hip, actua! Ips! rosidenoer and domidle ih ths Stats of Horida.
pnsert here a~y psrtinsM facK, wch as ~le of properry or butinsu, or relinquishment of emptayment
at formsr dormidle, removel of family b new domidle, purcha~ of har~e, atc.)
~ppl~iad for haseatead ~
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1 FURIHER CERTtFY th~t t will ropisMr at my local address when the roQi~r~tion books ~eopen, and oorr~ly with
all othsr. requirements of a le~al r~sidant of this Stat~s. ~
~ 1 FURTHER CERTIFY th~t 1 have no iMenfion tn rotum to my ~former domidls, and i~ntand to romein in FORT
PIERCE, SAIM LUCIE COUNTY, FLORIOA, permansnNy.
Snaeuo~ ~qrde~ra~~
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- ~ (A~ddross)
~ Sw~n ro and wbacrtbsd b~f+on mt tl~b l~th `.dsy ~ l~lebruary 19~.~
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