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Qeciarat~on of Domic~le and Cit~zensh~p
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TO TtIE CLERK OF THE CIRCUIT (:OURT. - 31~26
ST. LUC I E ~pV~y. ~,pRIDA: .
This is aqr decluation ot Domicik and Citisenship ia the State ot F'lorida tbat I am Ciltna tAts day tn acoor~anca. and ~n
conformity ~rith Sectioa 222.17. Florida Statutas.
I was forme~,lj~ a kgsl t+esideat oi s~N 5A/~m , N• ~ I
1(~t~?1 1~)
resided at ~D 7~~~~~& ~ However. I bave ehanged my domicik to
(8tr.~t ~ed Nwse.r)
aad am md bave been a boaa Gde resideat ot tl~e Stste ot Flodda since da,r ot
.19 ~
5 _ aad I ~eside at / gOlo .So . 7 ~ e~, ~
lSeewt sad NamDK)
~1~. ~i o~.~~ ~ ST. LUG 1 E Connty. Fbrida. 1
SDf~ «1L1 E1iLCIIlEDL ~ t0 ~~!D is IDy dlCliia~lOD O~ tIt1ZCOS~IIp. actual kgal residence and domieile in the State oi F'lorids.
I f fOR THE PURPOSE OP ENROII f NG ~ i ~`ti~ 1#~ii;€~ i~.`.~ ::;'~.°~~~5~
CHtLOREN tN SCHOO~~ PLE/tSE STATE PLEASE GHECKt ~
THEIR kAMESS
~ G~ E~' ~C' ~c~i» On/ U f~AC,C- ~
r~tEO 4k~• •:f~;L~~fO
ST I~ir;~ .,,i7~iYtLA.
f+~i~F = -~3~TRa
orCj.:=~.`:.. ~~~Tt,+ C'RT
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I FURTHER CERTIFY that I will register at my locai address when the rcgistration books reopen, and rnmply with all
other requirements oi a legal resident of this State.
~tl~'UR~{I~~ CERTIFY that I have no intention to nturn to my former domicile. and I inlend to remain in
f~/ei2Ce. Sr . L uC 1 E~ , County,
ICit~) .
Florida. germa en~i~ .
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Sworn to and subscribed before me this Ti, dt~y ot
- . A.D. l9 75
ROGER P01 TRAS, CLERK OF G RCUI T COl~2T
ST. LIJC I E COUNTY, f LOR t UA i
BY:
PUTY LERK
~ ~ a~ 244 ~1342
_ - /1C0 Form 71 ~?2
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