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Declaration of Dornicile and Citizenship
~ ~ , 3184'~5
TO TNE CLERK OF THE CIRCUIT COURT. ~
. ~
ST. LUC I E COVN'1'x. ~.ORID~:
Thb b my deelacatioa ot Domtcile and Citiun~hip in the State ot Florida tAat I ua Gling thia dar in aeeordanee. and in ~
tontotmity wlth Sectioa 2~.'.17, Florida Statutes.
I wu iormerl a legal nsideat ot ~h A~~ /a _ Q S S' ~ I
D tcur? ts~w1
resided at 7 G G~~ ~~~S/ I~e .~I" • _ Hv~rever. I bsve cbanged my domicik to
(8t~s~t +od Nuob~r) - ~L
tad am aad lu~ve been s boaa rde reaideAt of the State oi F'brida sinee . T a+?J? ot
~ 19_!~- ~nd I reaide at ~ 3 1 h c~i ~Q r1 A!'J r ~ r•
1 ~ (8q+~t a~d NombKl
7•/! P r c. e _ ST . ~ l1C I E Coaocr. ~or~a..
tcw~
and this atatement Ls to be takea ss my declaration oi eitiseoship. actual legd reaidenee and domic~e in tl~e State of Florida.
If FOR THE PURPOSE OP ENROILIN~ ~F ~'OR HONES'i~1lD ~i1~cFab~b~
CHILOREN IN SCHOOI~ PLEASE STATE PLEASE CHECK! ~
THEIR NAMES.
/~r-a ~~c ~'s i?i~~ F~ i'~ ~liis~i>>~ Jr •
i I» ~I ei~~y ~i~i7 ~a s7~eil~ .
fILEO "~GUROE~
' ~T.IUC+~ ~::;iNtY FIA. ~
f,vo: _ ":T''hAs
CIEFK ~~:ll ~OURT
aFr~.;,., yr
- ~ OCT ~ I ~ 32 AN'~5 ~
' ~ ~~84'7
i
I FURTIiER CERTIFY that I will register at my local address when the registration books reopen. and comply with all
other requirements ot a legal resideat of this State.
I Fi1RTH ~C ERT~
FY that I have no intention to return to my former domicile. and I intend to remain in
-~7' • ;~e t~ C~ ~ ~ ST . L U C 1 E , County.
j ~ca,~ .
f
~ FbridA. permanenti~ .
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~ Sworn to snd subscribed t?e~tore me this day of ~lL~,.~, ~i ~~.s~ ~~~4'_.~ •
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! l ` . A.ll.19 75 / .
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F ROGER POITRAS, CLERK OF GIRCUIT COU2T
i
r ST. LUCIE GOUNTY, FLORIUA
e
~ BY:
F UTY LERK
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¢ ~ ~-'R `~44 pacE15~4_
ec~x ~
' AGn Form 71 ~
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