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Declaration of Domicile ~nd Citizenship ' _
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TO THE CLERK OF THE CtRCUIT COURT. 32~ ~l ~
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ST. lUC 1 E cpuNTY. Ft,o~tmA: ~
This is my declarstion oi Domicik and Citizenship in the SLate oI Florida that I am i'~liag this dey ia ~eeordaaee. and ia
eonformity with Section 222.17. Florida Statutea. !
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I was fo~ a legal nsident ot S' TA.h~~~ D ~L' f c. Ti c t/ i~ I
Ic~url ~sc.e.~
re~~ it -SrJ"'~~u/BE,P
~/S/~.L~ AvF . Ho~rever. I have cbanged my domicile to
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aad am u~d have been a bona Gde resideat oi the State of Fbrids sinee ~3 day ot
t^ c E'~`~1Jt
~ , ~8~ .na T r~s;a~ ~c E'/~ sT p~. ~~9 s 7'~y ,Bd .
(Ste+~t ud Number)
PD~tT ST. LvG/~ ST. LUC I E ~Q~. ~ri~.
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snd this statemeat is to be takea u my declantion of eitizenshiQ, actud legal nsideace and domicik in the State oi Florida.
~ IF FOR THE PURPOSE Of ENROLLING IF POR HOMESTEAD PURPOSES~
CHIL~REN IN SCHOOL~ PLEASE STATE P~EASE CHECK: ~
THEIR NAMES2
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' I FUR7'HER CERTIFY that I will register at my local address when the registration books reopen, and comply with all
~ other requirements of a legal resident of t6is State.
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i I FURTHE~ CERTIFY thal I have no intention to return to my tormer domicile. and I intend to remain in ?
~ ~0~ly' ST ~ dGJt-'~ ~ ST . L UC i E . County. ?
~ ICit~l _
~ Florida. permanen~i; . ~
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~ S~a,prdt4~+±d ~Pl~b~ribe~ be[ore me this day of
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~ • ` • ' . A.D.19 76
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ROG ~ PO f TF2AS, Cl.ERK ~OF C I RCU I T COl~2T
~ ST. LUCIE COUNTY, FLOk1UA ^
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~ E P U T Y L E R K~_T~- BOU
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