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TU TNE STAIE /1ND CUUNiY T/~X n:~SI:S.SC~k, ~c~w~c
a.~Fi`3 J
51. IUCIE COUNTY~ FlOR1UA:
This is my decloration of ~omicile and Citizenship in thcs State of Ftorida that 1 am iiling this day in accordance and ~
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in conformity with Chapte~ 222, Section ?22.17, Fla~ida Statutes. . ~
1 wbs forme~ly a(egal resident of • r~~-~~Eti1' ~~cy~G~~ i
~ (City) (Stete) i
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and 1 resided at _ .~o -~~03 ~/~ST . However 1 have changed my domitile
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to and am and have been a bona fide resident of the State of Florida since ~ ~3~~ day of
~ /fo~TC ,Bah ~72 - C'C /S/I /dGUAY ~Ae)
'~~i~/L , 19~ and 1 reside at
- (Street a~d Number)
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA ~
and ihis statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Florida.
(Insert here any. pertinent facts,. such as sale of property or business, or relinquishme~t of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
- Entering children in school : ~
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- ~c~.~EL Q Co,~,~F~ ST.~~~~` COUHTY~FI~~. '
RO.SEF. F~iTR~S (
/ ~ L CIERK Ct~CUiT COURT
(~Of'~~Y V • v 1.~~~/~~- RFCORO ~F~~?~EO~
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1 FURTHER CERTIFY that 1 will comply with all other ~equirements 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 fo remain in FORt
PIERCE, SAINT LUCIE COUNTY, FIORIDA, permanently. '
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$w,~soF~o ~Q} ~bscrified before me this day of ~P~~L , 19~.
'~~?,i?at~.tt~ ~'a.; . .
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ROGER POITRAS
CLERfC CIRCUIT COURT Notary Publit
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Qy C ~ D.C. My Commission cxpires
, aoox213 w~~E -~86
(To bo oxoculed an duplicato ancl =-~nal (il~d wi11~ Clcrk Ci~cuif Cou~1, and duplicato with Tax Assoswr.)
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