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i U 11 iL SI Al L ANU CUUN1 Y T/1X n,~ ~l S:~Ok, ~ 253932
51. IUCIE COUNYY, fIORIDA: ~
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1hi: i: my dalorelion of pomicilo and Citizcnship in tho State of Floride tha~ I am tiling this day in accordance anc!
in co~(ormity wfth Chapler ?2?, Soction 22Z.17, Flarids Stetutos. , ' i
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I wst fo~morly a Icgel resident of ~
_ ~ ity) (Stete)
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e nd 1 ~etided st ~~,n ~.~,1 C p. ~~U . Howaver ! hava changed my domt~ile
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to end •m end have been s bona flde resident of the Stete of florida :ince _~r`~~7`_ ~ ~`17-3 day of
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' ~ , 19~, a~d 1 restde 'at ~ '
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FORT PIERCE, SAINt LUCIE COUNTY, fLORIDA _ • ~
~nd tht: :tstement ts to be taken a: my decla~ation of citizenship, actual teget residence e~d domicite in the State of Florida.
pnserf he~e any pertinent facta, such as sale of property or business, or relinquishment of employment
at forme~ domicile, ~emoval of family to new domicile, purchase of home, etc.) . '
Applyin9, for Homestead . ~ ~ .
- Entering children in school : ? . ~ '
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~ • CLfRK C RCUI COUR?
. . ~ECORO'VERIFIf D -
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~ 1 FURTHER CERTIFY thet 1 wiii compfy wlth all othor requirements of a lega! re:ldent of thls S1ate.
t I fURTHER CERTIFY thet I have no intention to retur~ to my former domidle, and 1 intend to remain in FORT
~ F'IERCE, SAINT WCIE COUNTY, FlORlDA, permanently. ~f/j~h~~~ °~b~~"'~
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~ G U I'T G` ' (Name)
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~ '9.rCE~orQ b,~t++~ subscribed before me thii day of ,~q,~~.~-
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~ ROGER POITRAS '
CLERK CIRCUIT COURT Nolary Public
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~Y D.C. My ~ommission cxpiro:
_ . 804~ !'A~f 2~VV
(To bo oxoculod an ~luplic+lo ~nd <••~nal tiluJ wiih Clork Clicult Cou~t, end dupliute with Tax ~ostor.) ~
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