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Dec~~ratic~n o~ Qor~~icile and Citi~~nsh~p
TO Tl~fl: STATI: Ai~D ('OUNTY 7'A\ ASSI:SSUR,
S t. Luc ie 266032
couN~rv, FLORIUA:
Tl~is is nzy drelaration of Uomic;ilr an~l C'itizcnship in thc Statc of Florida that 1 am filing ihis day in
accordanre, and in conformity with S~ction ??"'.17, Ftorida St:+tutcs.
1 was forn~ icrly a Icg~! residcnt of anc~-t
(cilr) (state)
resided at ~ ~ • ~
(Stre~t a~~d Number) , • HOWCYC~, ~ j1aVC changed my domicile to
and am and have becn a bon;i fid~ resident of ti~e Staie of Florida since day of
~ now
` , 19~ and 1 ~residc at ~ ~ ~
~ ~ ~ (Street and Number) r
. St . Lucie County, Florida,
~ ~Y
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State
of Florida. .
(Inserl herc any perlinent tacts, such as wlr of property or businrss, or relinquishment of employmeni at totmer ~
domicile, temoval of famity to new domicile, purchase ot home, rtr.)
Entering children in s~hool:
s~i~ ~oain s
RGS=~ ~ITR~$ 4~
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pEC011p.YfF!F1~D
~ 15 t ia PM '73
~ ;
~ 266032 - I
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i I FURTHER CERTIFY that 1~vill registcr at my local address when the registration books reopen, and
; comply with all other requiremc:nts of a legal resident of this State.
~
; I FURTHER CERTIFY that 1 have no intention to rcturn to my forn~er dor~iciie, and 1 intend to rem:tin in
~ ~ ~~t.S~.n~-~,.,
` St . Lucie County,
? Florida, permanrntiy. tc'~Y~ ' '
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~~'1:. . ~ ~r'.. ~1 ~ (Address ~ i
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to'and$i~sc`~i(~cd befom nte this dal' of 7~ ~
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. L,.'•:. : :~~.`.~''a;;:'.q;` '~Qbe 73
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~~~4~Eg0~'Q~tRAS, CLERK CIRCUIT COURT
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(Tt~ bc exrc~d~•d in Juphr.~ir ~nJ ~~n; m.il Idrd uill~ l lcrk ('inait Cuurl. and Ju~~b: •rtr ~c~th "fax AsKi~or) -
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