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Declarat~on of Domicie~ and Citizenship ~ ~
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TO THE CLERK OF THE CIRCUIT COURT. 3053~3 ~
ST. Lt1C I E Cotlt~r~r. FI,QRIDA: . ~
1'his is mr declaratioa ot Domicile and Citisenship ta tbe State of Florida thet I un Ciliag this day in accord~nce. and ia
eoatocmity with Section 222.19. Florida Statuces. . '
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I wu tormerl a leg~l resident of SQ ~ ra P~? ~ , ~v r' n,~4 and I ,
~ctty~ lSt.t.1
n~~ ~t ~~/QL~ !/Q /~e~ . However. I have changed my domicile to
at3tre~t aod Numb~tl ~t,
and am and have been a bona tide resideat ot the State oi Florida aince n e ~ 7• ~9 ~ 3 dsy of
.19_~ and I reside at ~ ~/q~+ r~a ~v ~
lStewt and NumDerl
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o r~t . P. ~ ST . L UG I E County. Fbrida.
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and this statement is to De taken a~ my declaration of citizeaship. actual legal residence and domicile in the Statis of Floride.
If FOR THE PURPOSE OF ENROLLING IF FOR HOMESTEAO PURPOSES~
CHIIOREN"IN SCHOOI~ PLEASE STATE P~EASE CHECKS
THEIR NAMES2 ~ 3
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FtIED ANO RECOADED #
. ST. ~UCIE COUNTY FLA. ~
~ ROCER POI;RAS ~
CIERi( CInGUiT COURT
RECORO VERIFI~D~
~ Ar~ 1 I a9 PH'~5
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' I FURTHER CERTIFY that I will register at my local address when the registration books reopen, and comply wilh all
' other requirements of a legal resident ot this State.
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1 FURTHE~ CF.RTIFY thal I have no intention to return to my former domicile, and I intend to remain in
€ ~f •P,'s;
c~ ~ ST . L UC 1 E ~ County.
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~ (Citr) .
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~ Florida, permancn~i; .
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~S~A'h~o a~ ~?~ribed before me this / day of '
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:h ROGER POITRAS, CLERK OF GIRCUIT COt~2T `
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~ ST. LUGIE COUNTY, FLORIUA ~
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, EP'U7Y~. LERK '
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• BOOK ~~JO PACE V~ •
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ACn F'nrm 71 ?2 `
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