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Dect~ration ofi Domici~e and Citizenship
TO THE STATI: AND ('OUNTl' '1'A~ ASSt:SSOK, 26S418
St.Lucie
_ COUyTY, 1~l.ORIl~A:
Tl~is is my dcciaratian oT Dc~mirilc and Citircnship in qic Statc of Florida that l am lilin~ this day in
accordancc, and in conformity with S~ction `"?.17, florida Statutcs.
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1 was farmcrty a Ic al resident of C~ `f . ~ , ?/J cL t1 c'c' and i
n (r~ir~ (s~.e~~
resided at « i-~~,
ly~-/~'~ ~ d . However, I have changed my domicile to
(sitZEt and_ Nu~nber) ~
and am and have been a bona fide rrsident of tl~e Statc of Florida since f-~-~ ~ t--~" day of
now J v
t~ , 19~~y and I /residc at _ ~ /-~'~LlCI~X . /
J (Street and Number)
~ /~t, . S t. Luc ie ~ i
~C~~Y ~ . County, Florida, j
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and this statement is to be taken as my declaration of citizenship, actual legai residence and domicile in the State ~
of Florida. • ~
(Inserf here arty pertinent facts, such as sale of property or businrss, or r~linquishment of employment at tormer ~
domicJe, removal of family to new domicile, purchase ot home, etc.) ~
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Entering children in school:
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FP,IFIED`_ ;
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265418
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t I FURTHER CERTtFY that I wi11 rraister at my local address when the registration books reopen, and ~
` comply with all other requirements of a le~al resident of this State.
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y RTHER CERTIFY that I i~avc no intention to return to my former domicile, and I intend to remain in
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t ~.h ~ ~ ~c_c-c ~a_- S~,. Lucie , CountY,
~ Florida, permanently. cc''~ .
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' .•~~j;.~„ . (Name)
~ ' y ` , ~ -~~%4~:~ s~ /
' ~f;,• ~ t~~'~: %y` - ~V c.~ ~~il~~ ~ C.~.,' "
y y~~' ~°~~C : A ~ ~ n (Address)
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; SvJ~o~tt~' ~~ct~t5@d bcforc mc this _ day of . ~IjJ" ~ ~ ~ ~ ~ .
k • v.
_ • ~C~''~~_ ~ n.n. ~ ~__73_
ROGE'R"PnITRAS, CLERK CIRCUIT COURT _ ~
gOTK~~7 PAGE~J~ ~
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_ - ~Y `D~puty ~~1
(To bt exeeuled in duphcalr anJ or~F~n a f~leJ ~.~th t'Irtk Circuit Cuurt, anJ Jupli~ate Nilh Taz Asxsso~)
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