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Q~cfarG~i~~ of i~orni~:~le and Citizensh~~
~r~ Tii~: s~~~n~~~~ nni~ coun~~~t' 1~Aa ASSlsso~i, ~C~152'~
ST. LUCIE _ _ ~~UUN'fY, FLOItIUA:
11~is is my ~lrclaratio~~ of Uomirilc an~l Citizcnship in thc Statc oi' Florida that 1 am tiling this day in
accor~lancc, aml in conformity with Scction 222.17, rlorida Statutes.
1 was forn~crly a Ir~al residcnt af - ~ and 1
(CitY)~ / (State)
msided at /~/i9~t~~~-~~ .}lowe~~cr, t have changed my domicile to
(Strert and Number)
.md am .~nd havr txcn a bona fidc residcnt of thc Statc of Florida since day o!'
-~L~,~.------ , 19~~_, ancl 1 nside at ~~07 -
~ (Street anJ Tlumber)
St . Luc ie Count Florida,
-fn,e~~1ER[~-- - y,
cc~n~) .
~:~~d this statcment is tu be taken as ~ny dcclaration of citizenship, .+~iual legal r~:sidence and domicilc in thc St:~te
c~f Florida.
(!nxrt here any prrtinent fscts, wch as sale of pwperty or huainess, or relinyui;hment of employmrnt at fotmer
dumicilr, remuca! uL family to ~~ew dur.licile, putchase of hume, elt.)
EN'TCRI~IG CtlILL~~~.d~,.IN S~Il00L: h0~`~ST~AD E~~rrn'!'IO'i: ~
If enterir:g chi~ldy~-r ~•in school, ~
please l ist ~heir nai~-ies;
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~ I FUR7~H(:K C[:RTIFY that i H-i3) m~~ister at my local addmss w;ten the registration boo4~ reopen, and
~ comply ~vith atl uthrr nquircm::n:s ~f a Ic~al residcnt of this State.
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~ 1 FURTIiL'•R CERTIFti` tha~ 1 b:i~•r no intcnt~on to rcturn to n~y fonncr domicilc, ~+nd 1 intcnd to r~n~ain in
~ s~r, i.uc~~
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~ S~,~ti~t~;~~'~~ ,'~bcd hcforr ~i~c this __1_~ day ot
~ ,t;~~:- A.l). 1~)_ ~7~ ~/c-S /~v/SC4J
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~ P.OGT:R PCT ;'RAS, CT_.I:I:K CI CtIIT CUUItT T c N~ ~ i loric:a
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~ By eP~,tS, C1~-r~:
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~ (7o bc r~rcutrd in d+~pl~~ati•:.uJ ~•ri~i„al fdcd ~~itb ('t~~~{. ('in•nd ( uu~l.:+ad dupliralr w'ith 7a? Aascswr)
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