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Deciarat~on of Domicile anei Citizenship -
460283
TO THE CLERK OF THE CIRCUIT OOUAT. - ~ -
8T. L0CZ8 - CovlaTY, FLORIDA:
This is W declsratlon o~i DomiciM and 4Yti:enship in the State at Floeida that I am BHns thin day io aooordance, and in
conformity with Ssctioa 2?,~.17, Floeida Statutes.
I was focmer~y a legal resident ~ G0$ _ ILLINO23 and I
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resided at 1~ ~'i :F81rf field Road _However, I have ehanaed ap doaaia7e to - _
(sa..t..drtiearl
- and am and have been a bona tide resident a~f the State of Florida since - the ~ f ism t day at
July ~ ,19 79 ~ i ~ P .C. Bvoc 513. Routs #3
_ teawtadl~i~e)
- Fort Pierce - St. Luais ~,ty,Flo~da,
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and this statement is to be taten as my dedaratioo of dtissnship. adnal lean) residence and domicils in the Stets of Plodda. _
- c9~9 SFP 26 AM 8 ~t3 _
~Ot~ITY FLA.
POITRaS
C41btt
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_464283
'i I F'[TRTHER CERTIFY that I w~71 register at my local address when the registration booms reopen. and comply with all
other requirements of a legal resident of this State. _
I FURTHER CERTIFY that I have no intention to return to my former domicile. and I intend to remain in
• FORT PtBRCE 3T . LUCffi _ County,
Florida, permanently- -
E
.p-~ - Rmc 51~ . Route #3
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Sworn to and aubecn'bed before me this ~ day of Ft • Pierce, Fla .
September A.D.19 79
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' ~ ~ Pair, Slate of fioede st Lasgs •
Dir. e~ ? , - 2 UR 7 PAGE
. • • . a'`~~ ~i~ tie e:cented is dupiiab and Drip al i31ad with Cierk (xradt Coae`t:. and dapliate writti Ta: Annaorl ~
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