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7'O'fl ll: S'I'A'i'l: A\I) COUN7'1' 'i'A\ ASSI~:StiUlt~ ~ :
236169 :
--,._-----_C'UU\'I'Y, I~LUltll)A: ;
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11~iti is my ~Irrlar,ition c~f 1)on~ic:ilr :~ncl Citixrn~hi~~ i~~ thr Stat~~ of ~loricla that t am filin~ this dciy in
accordan~~, ancl in conl'orniity ~vitli Scction ~'?.17, Fl~rida Statutcs. • ;
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1 was formcrly ~ Irraf residrnt of ~7~1,s~,4 ~c..L~~ ' ~ _ and I ~
~~p (cilr) (state)
residcd at ~~?~Q~ . Iio~vcver, 1 havc changcd my ctomicilc to ~
(Sltert and WumMr) ~ ~
and am and have bccn , a bona fidc r~sicicnt of thc State of rlorida since day of ~
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, 19_-~y and 1 resicic at 1~ ~ ~ r~~-~' j
• ( eet and Number) j
,~u-K~ . ~~-~'-4-~ ~ County, Florida, ?
(atr)
and tl~is statcmcnt is to be taken as my declaration of citizensl~ip, actual legal residence and domicile in the State
ot Florida.
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(Inseri here any perlin.nt facls, suel~ as sale of praperty eK ~ucinesc, or reliaquishment of employment st formet
domicde. removal ot tamily lo ne~r domicilt, purchase of home, e~c.)
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. FILEO AM~ RECOROEO ~
. ST. LUCIE COUNTY FIA.
• ROCE~ PGIFRAS ~
CIERK Cta:~~T COURT ~ '
pcr,ORr Y=r~F.EO__,_„ ~ -
~ ~ Auc 15 f I oi AH '11 ~C~
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1 FURT1iCR CEI2TII=Y tl~at t~~•ill rcgister at my local address when the registration books rcopcn, and
comply with all othcr requirements oC a lc=~l resident of this State.
I i'URTI~ER CERTII=Y tliat t ha~•e no intention to reti~rn to my formcr domicile, and I intend to remain in
•~'~c~ dS~ .~r~
, . , County,
Tlorida, pcrmancntly: (~'`r~ _ •
. - - ~ ~ ~ ;
~ ~ ~ r; T?iON~S W S V~m~j .
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!!G ' f _ ~ ..V
~I • t -
~ ~ , _ t . (AdJress)
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~ Svir~a~n.tQ.~nd;su`bscrihcd bcforc mc this day of
~ ^J ~ A.D. 19Zi -
.~`-C``'~ G" ~ ' '
otarr 1'ublic Sl~tc ut I I~~nda al I.a~'r •
fiOTARY PU6tIC ~I?~E of FLORIDA a~ • ~
YY COMI•"~ . S !aN. l~ 197b - •
1+1y Commiccion e~~~IRS_ nvFrs~TERS
(Tu Irr c~tcutrJ io dupliralr anJ u~~~in~l !8.•J ~~iU~ (l~•~k Citcuil Cour1. an JuplNa~r with Taa A~cr~wK)
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eouK~~ ~AGCZS~J
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