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~ec~~ ra~:~~n Q~~ Do~r~ic~~~ and C~~~ ~er~~:~~~p
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St.Lucie
_ _ CUUN7'1', I.O1tiUA:
'I7~is is my dcclar:~tion of Donticil~ and Citizrnship in thc St:itc af rloricla that 1 am filin~; this d;iy i~i
:?c~orJancc, :uul in conl~~~rmity ~vith Scctic~n ~22.17, Florid.i Statutcs. ~
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I was formcriy a tcgal residrnt of n~' , and 1 ;
/ • ( itY) (Stalr) `
r~•tii~lyd at _1 . However, I have changed my domicile to
(Sl~cet ~nd Numlxr)
ancl ain and have bccn a bona fidc resident of thc State ot Florida since ~day ot' i
DOW , ~
- _ , 19_-----, and 1 /~cside al -----`"~.L=~'--Q-~-n-~-a-- ~ 'd~' ;
~ ~ _ n ~ (Street and NumUer)
fl:~.~~-~--~-- _ St. Lucie County, Florida,
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and this statemcnt is to be taken as my cieclaration of citizenship, actua! legal residence and domicile in the State
c~f Florida. ,
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(lnserl here any pertineni facts, such as sale uf propc~ty or business, or telinquishment of employment at fotmer
domicile, remova) ot family lo neH• doroieile, purcl~as~ of home, rtc.)
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En~ering children in school:~ Homestead Exemption:
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r~~~o FECOaoEO ;
ST.IUCtE CJUNjY FIA. ~
RGCE ~_rO~TR~S +
CLE?K L; .~UtT COURT
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I FURTHER CERTIFY that I wil! rcgister at my local address when the registration books reopen, and
comply with all other rec~uirements of a lc~al resident of this State.
I FURTHER CERTIFY that 1 liave no intention to return to my former domicile, and i intend to remain in '
~i~ ~J~c~c ~ St . Lucie Count "
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Florida, permanently. {
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SNCOin to and:~s~ticd beforc mc this day of , ng a ress
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-~s~- n.u. f - I~~.~c.~ - 3 3~f-- 52
ROGE~ POITRaS, CLERK CIRCUIT COURT
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.'`@eputy -~Ie rk---~
(To be execuled in Juplicate an~l i,ti~~in:d filed ~~ith (Ye~k ('inuit Gnut, ana du~~ic~~r w,~h Ta. Assessot)
n ~ '~22 ~Z`'
BCCK~ F'~::•: ~J ~
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