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De~i~~ratian of ~Qr:~~cite ant! Citiz~r~si~ip
~ O Ti ~t SiAI t nNl~ CC~UN 1 r• rAx n~>>t.s~oc;, ~~Sb~a~
`;~i . t U(:il COUNi Y, Fl ORiD~~.
lli~s ~s niy ~Itclar;,tio~3 :,f U,^nc~l~r an~ Cilil~nshiF~ ti~ ihc St:~~~• of Floi~:i~ tt~at I f~l~ny th~s ciay in ac_currl~nce ari;~
;r, cor;lorr~~ity v.~~ih Cha~~tor 222, S~~~t~on ???.17, Ft.~rida Stasutes
I was forn~erly a legal i~sideM of _
S't~ ~2~1 _ . _ .__~.-.~i a~s'A ~ r_ i9
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and 1 resided at - '--a`- - - - -
1 ' ~ ~ . However I have choncJc~c~ my domic,i!e
(Street and Numher)
to and am and have bFen a bona fide resident of the State of Florida since ~ O . _ day of
A-U _ U S ~ _ , 191~ , and I reside at ~ !e~ T -~1T~ ~'1-~!',5-- - - -
9 (Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
and this statement is to be ~aken as my declaration of citizenship, actual legal reside~ice and domicile in ihe State of Ftorida.
Qnsert here any ~ertinent fads, such as sale of property or business, or reli~quishment of e~nployrrent
at former domicile, removal of farnily to new domicile, p~?rchase of home, etc.)
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CIERK C. :yU1T 60UR1 ~
'ECOIi~ VE~ ~+ED~.~~.L~
A~ 18 313 PH'11
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I FURTHER CERTIFY that I will comply with all other requirements of a legal resident of this State.
1 FURTHER CERTIFY that I have no intention to return to my former domi~ile, and I intend to remain in FORT
PlERCE, SAINT LUCIE COUNTY, FLQRIDA, permanently.
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~ c~;•l (Name) 5 c- / i d~~
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~ Sworn to and subscribed before me this _____t day of _~_7-~ U. S__~ , 19~-Z.~
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ROGER POITRAS
CLERK CIRCUIT COURT Notary Fublic ` ^
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~ ~Y ~ _ _ D.C. My Commission expires -
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~ (To be executed in duplicate and oric~inal filed with Clerk Circuif Court, and duplicatu wiih ?ax Assessor.)
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