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:l. WCIE COUNIY. FLOhIDl~: ~ ;
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This is my drela~atio~ o( Uornic~ic and Citizrnship in thc Statc of Florida ~liat 1 am filinc~ tl~is day in atco~danco a~J
in con(ormity with Cl~aptc~ 222, Section 222.17, Flarida Statules. , '
I was formerly a Iegal ~esident of e c~ !/V /~S C.
• (City) ~ (Stafe)
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and I resided at ~~~ou~ ~ ~?e-• • Howeve~ 1 have changed my domitilc ;
. ' ' _ (Street and Number) • . `
to and am and have been a. bona fide resident of the State of Florida aince 1~~ day of
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' U l.i NG ~ 19.1~, and 1 reside 'et ~ ~ _ ~oX ~/G •
i . ~ ' . (Street and Number)
FORT PIERCE, SAINT LUClE COUNTY, FLORlDA • ~ -
and this statement is to 6e taken as my declaration of citizenship, actual legal residence and domicile in the Slate of Flo~ida.
- (Insert here any pe~tinent facts,. such as sate of prope~ty o~ business, or retinquishme~t of employme~t .
at fo~mer domicile, ~emoval of family to new domicile, purchase ~f home, etc.) . _ '
• . . }
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~ ~Applying; for Homestead _ ~ • _
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- Entering children in school e r i ~e a N ~e ~v: ~ss ~r~ .
' ~ ~ ~ A~ n ~~~v.'.sse~_ ~
, ~ . -.c~~ ro,v ,•_,~'e r . .
- . : ~ ~ 2soo96 ~ . . - . . ~
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. . fttED Att@ REC4A p ~ " . . - - ~ ~ .
~ -$T. WC~E COUNTY ~~A.; _ - - - _ . ~ - • -
. "ROCER PGit1~A~ , ' ~ ' . ~ • • ~ . ~ '
~ ClE~K C'RC:lIT C . ~ ' ' ' ' .
: ~ ' . RECORD V~F'IFlFO • ~ . -
. ~,l~. 30 I 31 PM ~ 3 . . ~ ~ = _ ~ . _ - ~ .
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; 1 RIRTHER CERTIFY that I wi{I compty with all other requireme~ts of a legal ~esident of this State.
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G t fURTHER CERTIfY fhat 1 have no intenfion to return to my forme~ domiGle, and 1 intend to remain in FORT -
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~ PIERCE, SAINT WCIE COUNTY, FLORIDA, permanenNy. '
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Sworn to and subscribed before me this ~ day of , ~q~, -
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~ [tOGCR POITRAS , "
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~ ERIC CIRCUIT COURT Notary Pubtic
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; ~~Y Q~~'e'' ~ D.C. My Commission expires
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= (To be oxoc~led ,in duplica~e anJ ••~nal (ilc:J wilh Clork Ci~cuil Courl, and du~~licalo with Tax Assossor.j
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