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236182
'I'U 'I'l ll: S'fA"fl: A\I) ('OUN'1'1' "f~~\ ASSI:SSOIt, ;
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71~is is niy drel;~r.itiun c~f Uc~micilc ;u~d Citii~nship in thr Stat.~ of rlorida that t am Clin~ lhis d:iy in ~
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accorJan~r~ and in c:anformily ~viUt Scction 2''?.17, fluri Statutrs. ` i
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1~vas fonncriy a Ir~al residrnt of !X--~-~~ -~=~u - , and I ~
(City) (Slato) 4
residcd at . C~~ "l . Ho~vcvcr, I ha~~c changcd my domicile to ~
(Strerl and IVumMr)
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and am and have bcrn a bana fide residcnt of the State of rlorida since day of ;
~ ~'a 6 A. . ~
' , 19.~.~, and 1 resictc at ~
i7 (Street and NumAer)
v/~_ ~I~ , ~ ~~Lc-~ County, Florida, C
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and tl~is statement is to be taken as my declaration of citizensl~ip, actual legal residence and domicile in the State
of Florida.
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(Inxri here any pnlinent facts, sueh as sale of propertr or busincss, or relinquishment of employment at former _
domicile. temoval ot family 1o nc~v domicile. purchax ot home, r~c.)
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~ 236182 . .
F ~EO ANo aECoaoEo
. S~. LUCIE COUNTY F~A.
ROCER FOITRAS
CIERK C:RCUIT COURT -
RECOr~D VE-~~~1ED.~.~~. - ~
I~ 15 12 42 PM '71 ~
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1 FURTHGR CERTITY that i~~~ill rcgister at my local address when the registration books reopcn, and
comply with al! otl~er requirements of a le~al resident of this St~te. .
I PURTI~ER CE~ZTI~Y that I ha~•c no intcntion to rct?~rn to my formcr do icilc, and I intcnd to rcmain in
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~ - /~~~-~iuL ~ c-c'`'c., , County, ~
Tlorida, pcrmancntly: • _
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S~vorn to and subscribrd bcforc mc this ~ day of
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~ ~ ~ A. D. 19 7'Z-~ ' .
/G:rc~fc.~l~ 's ~
Nulary 1'ubli~ Slatc ut 1 I~~nJ~ a1 L~r~r~ ' ~
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My Crnnntis.eion rrpirrs ~~17~ • . ~
(Tu br cuculrJ in dupliralr and un~in~l fd.•J ~~ith Clr~k Ci~cuil Cnutl, anJ Juptw•a~r wiU~ Taa A+~rss~K)
ao~K205 ~~~E1~84
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