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D~cl~r~~~~~ c~f Qomi~~~~ ~~d Cs~iZ~~~sh~~
, 263'7S7 ~
I~O 1 ilt: STA'fi: ANI~ CnUN7'l 'fAX A~SI:S~OR. ~
SC.Lucie `
- _ ('UU\'I~Y, I~LUKIUA:
"I'Itis is my dcclaration c~f Uc~micilr :in~i CStiic~~shi~~ iiti tt~c Stat~ of rlorida tlt~i ! am filin~ this day in i
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ac~:orcfa~~cc, and in conlortttity with Srction 2?~.17; l=loricl~i Statutcs.
1 was forn~crly a lcgal resident of . _ and 1
, (citY). a1e)
rrsidcd at ~~~-~z~~!^~ _ Howcvcr, 1 havc changed my domicilc to
_ _ ~ (Strc~t and Number)
. _
_ _ _
and am and havc bccn a bona fide residr~it of thc Stat~~ of Ftorida sincc day oP
~Q~~~ now
~~-~:dt'3~ , 19_~ and 1/~residc at 3
. - : ~ (Street and Number)
3~-~1SL St. Lucie County, Florida,
(ci~r)
and this statement is to be tsken as my drel:~ration of citir.cnship, actual legal residence and domicile in the State
af rlorida~
(Insert here any pertinent facts, such as satr oi proprrty or business, or relinquishment of employment at former
domicite, removal of family to new domecite, ~urchase of home, etc.)
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RFCORpRY C!~'~~It COtI~ '
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I FURTHCR CERTIFY that I„rill rcgister at my local address when tlie registration books reopen, and
comply with all other requir~ments of a legal residcnt of ti~is State.
I FURTHER C~RTIFY that 1 have r~o intcntion to rcturn to my former domicile, and I intend to remain in
- ~ - ~ St . Lucie County, ~
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•~g~cro~'t~to and s~~hscrib~d b~ fum ;nc thiti ~ 7___ day of f
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- f~-r- - , A.f). 19__ 73
ROG~R I':~IT[tAS, CLERK CIRCUIT COURT ~ •
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t
_~y rn~ - y 6G?K 2~8 2t~3~ ~
Dep~~ty C _r.
(lo br raeculyd in duph~ .~tr .~+n! uri~:u~ ~1 hTcd a~ith t'Irr/. (ircuil ('uuit. rnJ du~•li:alc ~c~lh 't~x Asscytut) ~
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