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10 TNC STATE /1ND COUNTY T/1X A55CSSOft. 2~~~ ' ~
51. WCIE COUNTY, fLORIDA: •
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This is my declaration of Domicit~ and Citizc~ship in the State of Florida that I am tili~g this day i~ accordance a~d
in coniormity with Chapter 222, Section 222.17, Florida Statutes.
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t was forme~ly a legal resident of ^
(Ciry? (State)
and 1 resided at -~,,L~a'-.,~ Q'.~ l-._-~~ ~ Howeve~ 1 have chan m domiCile
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~ (Street and Number)
to and am and have been a bona fide resident of the State of Florida since _ ~ day of
~ - , 19~~ and 1 reside 'at '
_ t a~d Number)
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FORT PtERCE, SAINT WCIE C4UNTY, FLORIDA ~
and this statement is to be taken as my declaration of citizenship, actual legal reside~ce and domicile in the State of Flo~ida.
(Inserf here any pertinent facts. such as sate of prope~ty or business, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
~ Applyingj for Homest_ d ~ - .
- Entering children in school :
s~~~tF COUi1~~~, ~A .
. 110CER P~ItRAS ~
CtERR C~RC1~1t Cp11RT ~ '
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I FURTHER CERTIFY that ( will compty with alt other requirements of a lega) resident of this State.
1 FURTHER CERTIFY that I have no intention to return to my former domiCile, and I intend to remain in FORT
PIERCE, SAINT tUCIE COUNTY, FLORIDA, permanently. ~oS -t~jj T- lC D S/~
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SwoiK'1{~':`ar~~ subsc~ibe before me this day of ~~v~ 19~
.
ROGER POITRAS
CLEFtK CIRCUI7 COUR? Notary Public
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4Y - D.C. My Commission cxpires
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(To be oxocuted in duplicate and ori~inat filed wilh Clerk Circuit Court, an up icato with ax sossor.) ~
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