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~ ~ 4:30152
TO Tll~ CI.FItK OF TtIE: C1RCi11T ('O1~RT.
ST . L l1G 1 E _ COUNTY, FLORIOA:
.
This is my dcclaraiion o[ Domi~ile and Citizenst~ip in the Stale ot Florida t}ust I~m tiling this day in acconlance. and In
cuntormilv with Section 222.17, Florida Stntutes.
Ellicottville . - ~.Y. I473I andI
I was torm~~ s lcgul resident of - (Statel
tc~~y~
resided at I3 Jei re]G's~n Street , liowevor.I have changed m)' domicite to _
(Strcet aad I~fumber)
and am and havc been n I~ona tide resident of tho Staie oi Florida since ' 7t day o[
rtav . lA
7R
_ and I reside at 30I6 Overt~r nk nri ya -
- (3t~est and Numbe~)
Port St ~ Lucie ST. LUC I E County. Florida,
- - Iqtyl
~?nd this stater.~ent is to bc+ Laken ns my declaration oi citizenship. aclusl legal re~idenco and domicile in the Stute o[ Ftoride.
I F FOR TNE PURPCSE Of Et~P.OLI iNG I F FOR N01~fESTEAO PURPOSES~
CHILUREN IN SCNOOI~ PL.EASE STA7E PIEASE CHECK: '
TNEIR NAMES2 ~ ^ ~
F1LED~APID f2ECORD~Eb~
~UC~E C~?UNTY, Ff~LA. ,
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. 4:30152 ~
'79 JAf~ 9 pM 2: 59
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~ I FURTHF.R ('ERTIFY that I will register at my Ioc:11 addn:ss when the registration books reopen, and cumpty with all
! o.her rcquircments of a Iegaf msident o! this Statc.
' I FURTIIF:':~ CI:RTIFY thzt: ~l havc no intention tn rc~te~rn to my formrr do_
mtcile. and I intend io rem:,in in
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C 1 C . County.
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f Florida. perman~n~i;. ~
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