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39~795
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Dec~arat~on of Domtc~le ~nd C~t~zenship ~
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ST. LUC I E ~ ~ '
CQUNTY. FtARIDA:
Tbb b aq? deelara~ioa ot DoaaiciM aad Cititsnship in tM Stais at ~'loeida tl~at I aen ~ this d~ is a~oooc~daao~. aad ia '
eoaforeoit~ ~rith Saetioa 222.1T. Flaida Stattit~es. ~
I was fotmerlp a leasl r~~ident ot F 0 R T F i E R C E F L 0 R I ~ A ~ i ~
. . Ipt~? (Dta1d
~s~~ 2503 ROLYAT STREET B~~I~~~~~~ -f
(81twt a~i N~I~e~ ~
sod am aad ~aw baen a boaa ~de e~idRM at tbs $tat~ o[Flodds aiaos daT d '
19_ and I resjds d
~ (84wt na N~b.r) ~
Coltntl. ~'ioei~s. :
lClt~
and ttis statement b to be taken as m~ deelarstioo oI e[tlzem~hip. aetnal M~al resideno~ aad d~nidis in t!w 3tate al Flaeids.
I'.IAS BORN ~~f FoaT P~ERCEi F~pR~UA AND AM A U. S. GOYERt~MENT
EMP~OYEE...,I HAVE NEYER TAKEN UP RES~DENCE IN ANOTHER STATE~
AN~ MISN TO DECLARE THAT (/1N STILL A RES~OEN7 OF THE STATE
OF FLORIOII~ ANd ~NTEND TO REi~AtN AS A FLOR~UA RESlOENT~ EYEN
THOUGH MY P0517;ON 1~lTH THE UMl7ED STA~ES ~OVERNME~NT 1S SUCN
THAT~I ~tUST LIVE !N OTNER PLACES TtiAN F ORT PIERCE~ FLORIOA~ -c
UNTIL NY POSIT~ON ~S TERM~NATEO OR UNTIL MY RETiREMENT DATE. -
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i
t FuRTf~lt cEATIF7t t6st I.v~7! registe:.t my {oeal saaress when che regiscrstbn booka raopen. and oompl~ .vitA aD
other requirements of a kgal resident ot t6is State.
I FUBTIiER CEATIFY thst I bave no iat.entan to ntura to my formier domie~le. aad I intead to nmain ia~c
A CITIZEN _OF Sr_ L~c~F CALiNTY. Flf1R1I]A xp~~x
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l~'pSt~, penaanentlr.
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-'~ft,;~„„t„st~~` ~MER I CAN EMBASSY - USGAO
aPO 092 e5 r'uwa~.a -
Sworn and iubxribed before me tbis ~ da~ o[ E 1~/ YO a K~ 1~1 E M YO R K
A.D.19~C~ U- f{~L~C
E C~UN~~ Fi~. :
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Notart ({e 8tat~ d E1orida ~t iirp
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M Commission e: ires ~ ~ ~~R ~ ~ 4~
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Np'iARY Pr'411~ STATF nc ~OQtDA AT t~oCE ~9~~
~T CO~IMISSION QRIRES fFd. ?3. 1070 ~ •
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