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~i c> ~riic s'fATI~ Ahl) COUN~~Y Z~A\ ASSI'SSOIt, 26~28~
St .Lucie
___COUN'1'Y, t~LOltll)A: .
~I~itS IS 111y drelaratiun of Uomicilc ;ind Ciliz~nship in th~: Statc ~+f Flarida that I am filin~; this ilay i~?
~,ccor~lancc~ and in conforu~ity with Scriion ~~2.17, I~lori~fa Statutrs.
1~vas ibrmcrly a lcgal residcnt of ~,~,GA~-S ~~4~C. , ~U°~cR 5~ and 1
(c~~r) (s~~~o) ~
n~idcd at .37 ~~ol~ . No~~~cvcr, I havc chai~gcd n~y domicile to
(St~ert a~d Numbrr)
and am and ha~c bcen a bona tide residrnt of thc St.~tc of Florida since Q 7 day of
now
, 19~y and 1/~residc at _.__T ~ S~~sL~/
~ r ~ , (Sttett and Numbet)
~ L-l95Gt RC: n e i c ~=RC' c~'- St . LuCie County, Florida,
- (C~~y) •
and ti~is statement is to be taken as my declaration of citizensf~ip, actual legal residence and domicile i~t the State
or rlor;da. '
(Insert here any pertinrnt tacts, such as sate of property or business, or ~elenquishment of employment at fotmer
dortticile, remo+•al of family to new~ domicile, purchax of home, etc.)
Entering children in school:
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; 1 FURTHER CERTIFY that I will register at my local address when the rcgistration books reopen, and '
: comply with all other requirements of a legal resident of this State.
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I FURTHER CERTIFY that I have no intention to return to my former domicile, and I intend to remain in
:
S~ . Lucie
' ~/Q R ~ c ~f - , , CountY,
~ Florida, permanently. -
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(Name)~ ~ N O i~
_ .9 / ~e~v
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~ c ~ , . ,lsi S'N E/~su/'~; ~
~ . ~ r , t ~ (AdJress)
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' Swcrrnto~and~suifsca-ibcd bcforc me this~~~ day of .
~ '•'1`:- . A.D.19^73 . i
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~ ~.R4~ U~R.:F ~RAS, CLERK CIRCUZT COURT ~ . f
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i . - - . - ~ "~'~lbeputy Cl=er~ BO~f~ 'a~ r
. . .
(Tu bt executcd in duplicate anJ uri~~~nrl fded w i~h l7rrk C~ri ui1 C~~url, ~ud Juphr~~r ~ailh Ta• AsW ~,nr) -