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7'l~i. is t»y ~lrrlarati~»> ;~f Uu:u~~~ic c~n~l ('ilirr~t.lii~~ in thr Stat~= c~f l~lorid.~ that 1 am filing tliis day in
.~.<<~rdancr, a»d i~i rc~nfi~nnity ~vith ~~~tiun `?_'.17. 1=1~>rici:~ Stalutcs
1 was forn~criy a Icgal r~•si~ieni c~l~ __~~o~ .l~.~G~~~ -----f11.r~ fand 1
~ n (c:;ty> ~s r~
~ rsi~lcd at --~__oC._ l._, . _ t!o»~c~~cr, I have chan~cd my domicile to
G tt anJ Numbrr)
:~nd am :+nd ha~-r bc~i~ bo~~a fi~l~ rc,iclcnt of thc St:+t~ of t~lorida sincc day of'
- - - , 1 and 1 ~ow ~r at _ ~ - ~ ~x~ !~~ee/
~ (Stteet and Number
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--St • ~ _ _ County, i'lorida, :
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,~nd this statement is to br taE:cn as my dcclaration of citir.en~hip, uctua) t~•ga) residenre and domicilc in the State
of }~lorida.
(Insrri hcrr any pe~lincnt facfc, such as aalr ot p?operty or fimincss, ur retinyuuhment oi empluymrnt at tormer ,
domicile, rcmo~al uf ~am~ly to nca• don?icil~~, purchasr oi humc, etc J
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Enteriiig children in school:~ Homestead Exemption: ~
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2'~422'3 .
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I FURTHEK CERTIPI' that 1~~~ill rc;~ister at my tocal address when the registration books rcopen, and.
! comply with all otllcr rcq~~iremenis of a legal resident of~ tFiis Statr.
I rURTH~R CERTIf~l' that I h.rv~ no intcntion to rcturn to my fonncr domicilc, and 1 intend to rcmain in
__V_ _ ~ ` St. Lucie , County,
Florida, ner;manent~~I. <<~''''~ ;
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' ~ fi~'^: (Name) E
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SJvo ~.ti~it~~i~~ed brforc me this day of in re s #
, f = • ••.0~~_ A.D. 19 _7_4 _ g ' S ~
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ROGER POITRAS, CLERK CIRCUIT COURT ~~~s~
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(7u hc tarcutrit in dupl~: ~~r .~nJ nn_ ~i r fdrJ ~~iil~ /'Ir~k Cir~'uit Cnurl, ~nd Juplicat~ w-ith Taz Ac~ccc~~r)
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