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Q~c~~r«~~~n ai~ ~o~~ci~~ :~i ~i~~:r `
~i~u ~~~it: s~~n"fG A1l) COUI~TY ~rnx nssi~ssoit,
sC . ~.uc ~e 2~063~
. _ CUUN7'Y, ~LORIUA:
Tiiis is my drela~ation af Domicilc and Citizcnship in thc Statc of l~lurida that I arn Cling ihis day in
accordance, and in canformity-with Scrtion 222.17, rlorida Statutcs. .
1 was formcriy a tcg~l residc~Tt of Y'~ ~'C~ and I
T~ (citr) tsacc)
residcd at ~'a
O~ ~ ~ v~ . Howcvcr, 1 liavc changcd my domici[c to
(Street and Number)
ancl am and havc bccn a bona fidc r~sidcnt of thc Statc of Florida since day of
now ~ .3.Z -'lJ. ~ !7S ~ ~ ~
~'~~'~~`L6~~ , 19~ and I~reside at y !v~
(Street and Number) j
~Q % ~ C~ C i~ ~ S t. Luc ie County, Clorida, '
tc~~y~ _
~
and this statcmcnt is to be taken as my dcclaration of citizrnship~ actual legal residence and domicile in ilic Statc ~
of Florida. .
E
(Insert here any pertinent tacts, such as sale ot property or businrss, or relinquishment of emplo}mrnt at formet ~
domic~7e, temoval of family to ne~v domicile. purchase of home, etc.)
~
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4
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EnCering children in school:~ Homestead Exem tion: '
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- ~ ~ ~~t~E CO~tY FI.A. `
l~C=~t Pp1TRA3
. Stf3tl~ ;Ct9CiitT CO~iIIT
RFtORO YfAt=lf4
~C ~l 21 ~'7~
~'~0637' ~ ~
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I FURTHER CERTIFY that I~vill register at my loc:al address when the registratian books reopen, and
f cumply with ail otiier requirements of ~ leaal resident of this Statc. ~
,
I FURTHER CERTII=Y that I havc no intention to return to my forn~er domicilc, and I intend to remain in
' ~ ~
; •
; ~O~G/ S%- ~ vG~~'i St. Lucie County, 3
,
~ ~ Flori~la, ~~crm~ne~U}~.. cc~tr~ • ~ i~
~ , ~ . - ~c• C,''G.F-~ / ~ .
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/ n1: - . (Address) , ~ r
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Swor~o~i$d Su`b.qcribcd Ucfor. mc this day ot
, c , ~ A.D. 19 73_. ~
~
ROGCR POITItAS, CLERK CIRCUIT. COURT ~ fi
- - • ' ~
; _ s _ . . . ~ - - 4 - ~ ~'Ylt_ _ ct,~,~/ t) R ~ >
. _ y p~ t_y C7 t-k t'` 80JIt~ ~~a ~U ! ~
? (To I~c executcJ in d~q~li~ alr .~nd uri~•in.~l Id~vl h Clril. ( ircuil i'nurl. ~nd Jupl~.aln wHh "1.~~ Aucsw~) . . ~
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