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51. IUCIE COUNIY~ FLORIDA:
This is my declaralion of Uomicile and CitiYCnship in tho State of Florida ti~at 1 am iiling this day in attordance a~d
in conformity with Chapter 222, Section 222.17, Florida Statutes. . ~ ~
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1 was fo~merly a tegal ~esident of y~s~~ ~9~vT ~ _ ~
(Ciry) (State) ~
.
end 1 ~esided at FU F~~IN - . However 1 have changed my domicile ~
• ' (Stteet~ and Number) •
to and am and have been a bona fide resident of the State of Fiorida since F~u2Teeh T~ day of
_'~~L[ 1U l= _ , 19Z~, and I reside 'at '~~7 s,W vD /2~ ~l~ S i• K i S%, ,(u c r e. _
- (Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, fLORIDA '
and this statement is to be taken as my decla~ation of citizenship, actual legal residence and domicile in the State of Florida.
(lnsert here any pertinent facts. such as sale of property or business, or relinquishment of employment
sf former domicile, ~emoval of family to new domicile, purchase of home, etc.)
For Nomestead pu~poses and ~ _ - .
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• ClE1tK CtRCUIT COii~t
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• - - 2~3Q82 -
1 FURTHER CERTIFY that I will compfy with all other requirements of a legal ~esident of this State.
1 FURTHER CERTIFY that I have no intention to return to my former domic.ile, and I intend to remain in FORT
PIERCE, $~tLw'1 LU ••C~p~i~, FLORIDA, permanently. '
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Sworn to and subscribed before me this ~ day of ~ . 19~
ROGER POITRAS
CLERK CIRCUIT COURT - Notary Public
ny D.C. My Commission cxpires
(To bo oxocuted an duplicato a~d ~-••~nal fi1~J wilh Clork Ci~tuit Court, and du licato witl~ Tax Assoswr.) _
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