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ST. LUCIE CpUhTY; TLORIDA: ~ ~ . ~
This is my dcclar~tion of Domicilc and Citizcnship in thc Statc of Florida that i:,m filing this day in
acooc~dance, and in conformity witl~ Scction 222.17. i7orida Statutcs. ,
I was formcrly a lcgal resident of -,-~..~~--~'r'"•"`~~ ~ and I
- - (a~r) (s~~~e)
resi~ded at l~-~ ~_~s~ 3-~ ~ . Ho~vcvcr, I havc changed my domicilc to
~Stceet asd N~mber) ~
=nd ara and have becn a bona fidc resident of the State of florida since day of
r~ = 7 ~ ~c~- ~ l
z~~~ . 19~y - and 1 reside at ~ -
~ v ^ ~ (Slceet aad Number)
ST LUCTE _ County, Florida,
- - c~s) - -
and this statement i~ to be taken as my deciaration of citizenship, actual legal residence and domicile in the State
of Florida. - .
(Lsai l~e a~y pertioest tuts, sach ss sale d propertr or business. or reliaquashmrnt ot cmpldSrmcnt at forme~
ioaaeie. rea~oYal ot taasil~r to ~err domicile. pu~chase of home, ete_)
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Applyi.ng for homestead : . _ . . _ . ~
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_ ~ Entering children in school : ~
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Other: - - ~
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261933.
I FLJRTHER CERTIFY that I will register at my local address when the rcgistration books reopen, and
comply with ail other rcquirements of a legat resident of this Siate.
I FURTHER CERTIFY that [ ha~e no intention to return to my former domicile, and I intcnd to remain in
~ ~ J St. Lucie , Count
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~ Fiorida, per~e ly. (~o u Llc S~
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~ •.`p;~s{' (Name)
a''~,~~a • ~ ~
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t_~s r.'; . ; t = ~ (AdJrcs~)
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I~~,,,.~~~ ciibcd bcforc n:c tt?i; day of
D"~.~'
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t~ _ A.D. i 9_ 73
'r:C)CEF. POITi:ASi CLElt}: CIf~C IT COU;:T -
I~y D.C 6~~7 PJ16f~
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