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- ~ecia~ation ot Domi~~elaet~',Citlzen RECORDED
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To n~~ sT~~ ~wo couNnr Tac ~ssESSO~, o;;,' ~ 196i .lUL 3 I_ PM 3: 5
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n. ~vae cou~mr, FIORIDA: •~i ROGER POITRAS. CtERK
S~, I~CiE CBUNTY. fLOB10A
This is my declantion of Oanidl~ a~d ClNzenship 1~ ths ~State af Florida that 1 am filin~ thi: day in aooorda
in conformtly wlth ChaptK 2Z~, Ssction 2~4.17, Fforida Statutas. '
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1 was ~orm~?ly a ip~l residenf of .
(Cib) (Sta»)
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and 1 rosidsd at a-+.•-t~~ Hev+rever i hsve chsrped my dontidle
(5heet a~d Numbe~)
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` tp ~~d ~m a~ai hav~a been a bona fide rosident of the Shts of florkla sinos dey of
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19~~ and 1 roside at /r-~ •3 v
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FORT ~lERCE, . LUCIE COUNTY, RORlDA
and this statement is ro bs taken as my dedarat~on of dti~snship, ictual fe~al rosidenas and domldle i~ the Stsre of Horida. r
pnssrt here any pertinent facn, such as ssle of pfoperty or lwsir?ess, or roltnguishms~nt of amployn~et , :
, at former domidle, ronwval of farr~ly to new domicile, purchass of horne, etc.)
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I FURTHER CERTIFY that t will comply with
all otF~sr roquirements of a legal resident of this Staro.
~ I FURTHER CERTIFY that I hsve no intention to mtum to m er domi~fe, and i tni~snd ta ramain in fORT
PIERCE, SAINT LUCIE COUNTY, FIORIDA, permanentty.
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; Swom to and wbdatbd befon n+~ this ~i da ~q~~
~ ROG~ rOtTRAt
~R " Notary Pubik
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