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Dec~ara~ian af Dom~cile and Citizen~~3~
"('O Tlil: STATI: Ahl) ('UUNTY TAY AS51=.SSUR; 263236
~ SC. Luc ie COUN't'Y, i~ LURIUA: ~
'll?is is my dret,~r:?tian of Uamiciir ana Citirruship in thc Statc of rlorida that 1 am lilin~; this day in ~
.~ccorcla+trr, and in conformity with Scction '_'"'2.17, I~brid.t Stattrt~s.
1 was forn~crly a Ic~;al resident of ; Y~'e }~g ~ _ -,^~'Q~Y12~- and I
(ci~y), (s~a~~~
resided at ~~d _ 1J`_tQ~~~~~ . However, I ltave changed my domicile to :
• ' (Strtet aoJ Numbcr) • !
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and am and i~a~te becn a bona fide resident of the Slate of rlarida since ~ day of ~
now .
U `t-----_-- , l 4> und. I /reside at _3 ! ~ ~ ~ 1 ~ ~
~ ' - (Street and I~umber)
~~,p "j~ ~ ` , St. Lucie _ County, ilorida, -
(c~~r) }
a,~d tl~is statement is to bc taken as my declaraiion of citizenship, act~iai legal residence and domicile in the State
of Florida.
(inseri here aoy pertinrnt facls, such u sate of pruperty or businrss, or telinquishment oi employment at tormer
domicile, removal ui family to new domicile, purchue of home, etc.)
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Entering children in school: t ~
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fLLED ANf3 RELQ1p1E!
' bT. WCIE COtrlliT Rll.. ~
ROGER POITRAS
CLERK C~nCUIT COUi1T
RECORD YrR!FIEO
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26?323~
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` I FURTI~ER CERTIFY that I wiil rcgister ai my local address when the registration books reopen, and
~ comply ~vith all other rcquirements of a lega! resident of ihis State. .
I
€ I FURTHER CCRTlFY that 1 have no intention to return to my former domicile, and I intend to remain in ;
t
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} ~t:~ ~C St . Lucie -
_ County,
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~ - ~--L~:.• - A.D. 19__ 73_.
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~ KOG~R PUITRP,S, CLEItI: CIRCUIT COURT
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