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41.22
H LE1tK DF THE CIRCUIT COURT.
TOT EC
3
ST LUCIE
COUNTY. FLORIDA:
3
This is my declaration of Domleile and Citiseaship in the State of Florida that I am tiUag this day In aeeordanoe. and is
eontoraaity with Section 222.17. Florida Statutes.
N pr{tJICN ~ OIVWECT'~CUfaudI ~ ~ t~
I was former! a legal ro.±ident of - -
. tC'g71 (State)
resided at ~~~-a
~ U E B~i4R Y L C. ~d 19 ~ _ Howevsr. I have changed my domicile to
lstr..e aad IV 6 .µt
and am and have been a bona fide resident of the State of Florida since ~ ~ i `
~~6RU~RY ,1979 -aadIresideat '`-9/~ m YRTC.~ ~ Rl uc
~0 ~4 t ~l ~R c c ST . L UC I EStraat.aa Naearl County r •
lCUyl '
and this statement is to be taken as my declaration of dt,isetuhip, actual legal residence snd domicile is the State of Florida.
If fOR THE PURPOSE OF ENROLLING IF FOR HOMESTEAD PURFtOS S,
CHILDREN IN SCHOOL, PLEASE STATE PLEASE CHECK:
THEIR NANESt
r~ I ~ E~~N m ~Xw<«_
_
. ~O W u `_D
B~,Q i
_ rYI /4 >EC,Jt=C.L FILED AND RECBRIyE`6~ _
S LUCIE COUNTY; FLA:
• cc~CR'' ~lERIF!EO _
. ~ 4a3a~~ -
'T9 FE6 6 AM 10:56
s~~
f;OuFR ~Ot~RMS
CLERK C~RCtJ~T COURT
I FURTHER CERTIFY that I wt11 register at my local t?ddresa when the registration books reopen. and comply with all
other requirements of a legal resident of this State.
f I FURTHER CERTIFY that I have .no intention to return to my former domicile. and I intend to remain in
U C 1 E ,County.
t=~ 171 ~
Floridt(,~linaneutit:
. '
. ; S>L~. .
r
•`a ~ i~M y.
r::~~``
• _
7l O BEK~' ~ . l~[l4k WFI..L
SS ~ !Haase
~ ~ R c u c ~
~ tAddreee)
T`ORE' ~ cL.oR~AR 33 So
~ Sworn to and subscribed before me this day of ~ ~ Q
C E - l
. A.D.19_ t
~i
79
ROGER P01 AS CLERK OF C IR UI T COURT t
ST. LUCIE COUNTY, FLOR1dA
8Y: j'-
EPUTY LERK
s~K ~l2 2549
i A(:O Form 71 _ ~
i
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