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ST. ~1.UCIE _ ~•t)UNl'Y, I~LUftll)A: ~
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'lliis is my declaration ol~ t)amic=ilr and Cilixcnship in lhr St:~t. of Flori~la that 1 am filin~; this ~lay in
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;~~c~nlancr, a~ul iii rc?nfc~rniily ~vitl? Scclic~n 2"_'2.17, Flurida Statutrs. ~
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1 was formcrly a Irgal rrsidcnt of _~R.L~i_~~~~! ,~~~~1 and I ~
(CitY) (stale)
rrtii~icd at 7~_?_`-R~!'! ~@-.LZ~~[~r . Howc~~cr, 1 havc changrd my domicilc to
(Strcrt and hwnbrr) ~
ai~d am and havc bccn a han.i fidc rrsidr.~it of tlic St:~te of ~lori~la sincc ~~~s day ot~ ;
~/9N.i~.c--~ - ~ eS~.± Q~r t _ .ST _ _ ~
_ , ) 9_,2~ , an~l 1 rrside at _ - i
(Strrel and Numbcr) i
St . Lucie County, Florida, ~
~ ,es - 5 L_~_~st_~ - - - ~
(c'~ty)
;:ncl this st:itcmcnt is to bc takcn as my dcrlar.ition of citizcnship, actual Iraal residcncc and domicil~ in thc Statc
uf Florida. '
(In~rri herc any prf~inral f:~ris. <.uch ac s~le of pruprrly or buciuc», ur relinyuichmrnt of cuiplo)'mrnt at former
do~nicilr, «~»~~•~i ~~r r~~~~~i} a~,~~:~.a.. ~~~,~.i:asc of Aomr. ~tc.) j
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E"+'iERI`IG CHILDRE'.: T" SCHOOI.: ~ 1i0:~~S"T'EAD E\CAIPT70": ^
If en~e-ring childre~~ in school, ;
please I ist their na*-ses : ~ 3~, ~
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sz. ~u~~_ ~cURTY F~A.
R4GE~ ~'D'T~AS ~ :
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CLER~, C;CtltT COtlRT G F
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i . f 5 I 24 PM '75
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1 FURTt1t:R Ci:RTl1=1' that I~rill rr~~istcr at my local ~~ctdress «~hcn the registratic~n books r:•ei~rn. and
rc~ntply w~i[h aU otlirr rrc~!~iri mrnts ot~ l:;~al msictrnt ot~ this Statc.
~ 1 I=UR1't1E=.R CER"1'IFY that I ha~•r ~~o ini~:nti~~n to r~turn to my f~rmcr c;omicilc, and 1 int~nd to r~main in
~ ST. LU~I~ C•uunt~•,
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1=lorida, pE:rm.in~ttily. (c•~~y~---
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:S~rnt'~rii~`wncl s1il~~e~zd heforr i~~r t1~i, _~~day of /
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s~ ~ tic~G r 10 ~ i.~ia
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R~ ~ Det~ut:}? C1 r.;
rrulcJ in Jn~,licatc :mJ ~.r~~in.~l filrJ ~~ith 1'Irt~: ('ircuil ('uuil. anJ duyh~'ilr v.~lh la~ Ac~ctiu~r) '
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