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Declaration of Domicile and Citizenship
501Q6'7
TO THE CLERK OF THE CIRCUIT COURT.
ST . LUCI>5 ^ COUNTY, FLORIDA:
` This is aqr declaration of Domie~s and CIti:enship in the State of Fbrida that I am !fl{ns this day in aooor+danos. and in
eonfocmitr with Section 222.17, Fbrida Statutes.
I was formerly a legal resident of De 1 aw are Ohio ~ I
tpc~l ism
resided at 123 North Franklin Street Rowever,Ihave
• ist,..t..aN..e.r) changed rev doa~ieile to
and am and have been a bona Ede resident of tbs State of Florida since the 15th ~ ~
September ~ , lg 76 , a~I~~e~ 1640 Seaway Drive
(8trest ar Noob~t)
Fort Pierce St . Lucie Count. Florida,
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and this statement is to be taken as mfr declaration of citirenship, actual Issal residence and domicile in the 84te of Florida.
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I FURTHER CERTIFY that I wi71 register at mT local address wben the registration books reopen. and eomplT with at!
other requirements of a legal resident of this State.
I FURTHER CERTIFY that I have no intention to e+eturn to m~ former domicde. and I intend to remain in
Fort Pierce St . Lucie Count.
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Fbrida, permaneatl~.
r
Leo Wilson tAl.md
1640 Seaway Drive. Fort Pierce FL
tAed~w.)
Sworn to and subscribed before me this dar o[
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My Commission cspires - " - }
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