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'f0'flir: ~ I.F.ItK Ol'' TIIE CIRCUIT COURT.
ST. LUC I E COUNTI', FLORIDA:
This is my declaration of nomicile and Citizenship in the State of Ftorida that I am Cling this day in accordanco, and in
conformity with Section 22'1.17, Florida Statutoa.
1 was former) a legal resident of !-Iar~over ['aZk Illinois and I
ICitr) ~ (State)
resided at 76f39 Nort htva v nr ive - , Howovor, I havo changed my domicile.to
(Street aad Number)
and am and have been a bona fide resident of the State of Florida since ebr uary 2 day of
re]~_.19~2. and I reside at
aad Number)
tort Pierce ~ ST. LUC I E Couaty,Florida, -
lCitl)
and this statement is to be taken as my declaration of citizenship. actual toga) residence and domicile in the State of Florida.
IF FOR THE PURPOSE OF ENROLLING IF FOR HOMESTEAD PURPOSES,
CHILDREN IN SCHOOL, PLEASE STATE PLEASE CHECK:
THEIR NAMES:
Fri n A C*nl~~.,,,~,~
FILED AND REEORDEO~
L'.;CIE COt1NTY, FI.A.
'79 FE6 5 PN 2 ~ 49
. CLERK C1RCl11T COURT
I FURTIIER CERTIFY that I will register at my local address when the registration books reopen, and comply with, all
other requirements of a legal resident of this State. -
I FURTHER CERTIFY that I have no intention to return tom former domicile. and I intend to remain in
U C I E .County,
i
I ICit~) .
Florida. permancnti; . -
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6 ~ ' -
- ~ ~ f,~'~~ Sh ton E Sffiith
- - 6~~1 5. 23rd -St.
(Addrew)
Sworn to and subscribed before me this day of ='ort 'ierCei rla. 3~4,~,4 _
~ . A.D.19_
FOGEY POI TRASH CLERK OF CIRCUIT COURT
~
ST. LUC I E COUNTY, FL.OR 1 UA ~ -
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