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Deciara~ion af t~ornicile a~d C~tizer~ship
~rc~ -riit: s~~n~~t: n~n c•oun~rY •rn~ f~ssi~ ss~it. 265229 ~
St.Lucie
- - ~'~~un~~~~, i~ ~oiti nt~:
71~is is mp drelar:ition of I)omiriir :u~~l Citir.~nship in thc Stat~ of t~loricla th:it 1 am filing this daS~ in
arcord:~ncc, aiid in rc~nfurmity ~vith Srction '_?,.17, Florid.i Statutrs.
1 was fonncrly a Irg:~l resident of __,.~i_fll_L!~2-Tu - - and I
- ~ (state)
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residcd at ~'1~'3 - However, 1 have chanbed my domicile to
(Sttert and Numbrr) •
.lll(I am and have bcrn a bana fidr r~sidcnt of thc State of Florida since day of
now ~
1~._ , 19_ and 1/resi~lc at /}~m od u ~ s~ .
(Stteet and Number)
! / . J % ~ uG~ ~ St . Lucie County, Florida,
- (c~~r)
and this statement is to be takcn as my derlaration of citizenship, actual legal residence and domicile in the State
of Florida. ~
(lnsert here any prrtinent facts, such as wle of pr~.perty or busir.ess, or relinqui~hment of employment at former
domicile, temoYal of family Io nr~v d~~micile, purchase of hume, rtc.)
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~~LNCIE COIfMTY F1.~-
RBLf? F3!TR~S
C1.ERK CiRCUt~ COURT
REC4P.'; YE~!FIEO
~ Oct 5 IZ ts PH'~3
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~ 1 FURTHER CERT(FY that [~~~ill rcgititcr at my local address wher the registration books reopen, and
~ comply witli all othcr requirements of a Ic~al resiclent of this State_
~ I FURTHER CERTIFY that I have no intcntion to rcturn to my former domicile, and I intend to remain in
~
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~ ~f~ ^ _ ~ St . Lucie , County,
~ (c~~y )
Florida, pcrmanently. ~ S_ ~u- /?G ~
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y . . t i • • r, = . . T~.---L~CL~
, ~ (Name)
~ : - ; ~
: ~ " . . ~ . : - G~~'.l ~ - -
- • ~ : . - _ (Aaa«ss~ ~
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~ =Swdrn~V:a~'td subscs7l~rd hefc~rc m~ thi~ _.~~day ot i
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' •'f` ' - 73 4
~ ~CL` ~ _ A. I). I') _
;ry, -
~ RO~GCR"pOITRAS, CLERK CIRCUIT COURT i
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epu,.~r Cl er I
s;~ (Tu bc r~rcutcJ ~n dnpl~ialr .~mt ~,n••iu.~l f~ ~J ..ith l'Ir~~, clr.uit 1'~~ur1..~uJ Jupt~..~tc ~~~Ih Tr~ A~x~wit) ~
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