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ZU lllE STA1L ANU CUUNIY 1I1X 1~:.`.! ;;.C1k. .
51. WCIE C4UN1Y. F~oR~uA: 25~23
This is my decla~ation of OomicilQ a~d Citijcnship in tho S~a~o of Fto~ida that 1 am (ili~g this day in accordancs antl
in co~(ormity wilh Chapte~ 22Z, Secl;on ?22.17, Fla?ida St~tutes. , '
1 was fornnerly a legal ~esident oi 8 v R N E,tJ/?S 4 I/~
.Y L v
(City) (S?tate?
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and 1 resided at ~ 3 '~'1- E/vA R~ ~ J~,. ,~~„~eve~ 1 have thanged my domitile ~
' ~ (Street and Numbcr) •
~o and am and have been a bona fide ~eside~t of the State of Florida since 1~ dsy of
Y<~ . 19~-3 and 1 reslde st • 1~ 01 ~ ~r.~ S'f' v e 0.~ J e~
_ ' ~ (Street ar?d Number)
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FORT PIERCE, SAIN? LUCIE COUNTY, FLORI~A • ~
and ihis sfafeme~t is to be take~ as my decla~ation of citizenship, actual legal ~eside+oce and domicile in the State of florida.
pnsert here any pehinent facts~ such as sale of prope~ty o~ business, or reli~quishment of employment
~t forme~ domicile. removal of family-to new domicile, purchase of home, etc.) '
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Applylnq, for Homestead _ ~
- Enterinq chi~dren fn school : C F-E R! STi' ~ i9 1' F~ sr'~ .
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_ • tttEO AMO ltECOR E ~
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• CLEBKCQI~CVt~ CO~IRt ~
, . RECORp VER~FI~p - •
•
. . - - A~ ~3 OS ~M'73
. 2S~Q23
1 FURTHER CERTIFY that 1 will camply with a!1 other requirements of a legai resident of this State.
1~URTHER CERTIFY that 1 have no intention to return to my fo~me~ domi4le, and t infe~d to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanenfly. '
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''~r ~i1 t` ~shd ~Lbsuibed before me this day of
ti. ~?r~': ~ , -19~.
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ROGER POITRAS "
CLERK CIRCUIT COURT Notary Pubiic
.
rsy _ O.C. My Commission expiros
(To wo oxocutod ~n ~I~•;. ca~o and ~~~~~at filcrJ wili~ Ctork Ci~cuit Cou~t, ai.d dupiiulo wi~h Tax A:iosior.)
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