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Declaration of Domicil~ and Citizenship
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7+0 TI~E CI.ERK OF THE CIRCUIT COURT. ,
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ST. IIJC I E apU~y. ~,p~~:
'1'his ts ~ d~elsration ot Doanicik and C.~t~teas~ip is eM State o[ Flo~id~ thst I am Slin~ thL da,~ in ~ooo~+d~aa. aad in
aoetatait~? ~?I!D ScetioA 222.17. Flo~ida Statut~s. ~
I was f nc a iasai resfdeat ot _/~'~~.-•r--~-~.-~.-~..o-~~ _ • aod I
- - t lat~W
r~sided st However. I I~ave ehan~ed m,jr dodnicile to
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sod aan and l~ave been a boas Bd~ re~deat ot tbe StaLe ot Flaids since da,~ ot
G~-c"~`-~ -19~ and I t~eside at ~ ~
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aad t1~s atatement Ls to be taken ~s nqr dee3aration ot atixensbip. actnal kgal raideoee and doonie~e ~n the St~ate ot ~'ta~ids. .
IF POR THE PURPOSE Of. ENROL~ING Ii iOR HOMEStEAO PURPOSES~
CNI~aREN IN SCNOOL~ P~EASE 87ATE - rLEASE CHECK; ~
THEIR NANESt ~ ~
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I Fl1RTfIE1i CERTIFY thst I w~71 register at my la~l addres~ wben the registntion books r~eopen. and complr with•all
otber requiremeats oE a legal resident of this State.
~ I FURT'HER/ thst I have ao inte~tan to nturri to inr lormer domicik. snd I intend W remain in
_ • ~ S T. L U C 1 E ~ County.
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Fbrida. Permanenti; . ' .
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Sworn to and subseribed before me this ~ day of ~-~7~ ~.-~e;t.,~
~--~~'__'~c~,~,h ~ r ~ A.D.19 7.~ ' .
. ROGER POITRAS. CLERK OF CIRCUfT COl~2T
ST. LuCIE COUNTY, fl.OR10A
BYs
TY LERK ~2~ ~ Q~
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