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Deciaration of Domicile and Citizenship ~
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TO THE CLERK OF THE CIRCUIT COURT. 32~
ST,~ L UC 1 E Cuut~'ry~ FL~ORIDA:
This ia mp deelaration ot Domicik ~nd Citir.enship in !he State ot F'lorida that I am C~ltng thts day in aceordanee. and in
oontormity with Scetion 222.17. Florida Ststutes.
I waa tormerl a Mga! n~ident o[ T ~
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resided at ~G ~~~ti' - However. I have changed my domicile to
(3tre~t aod NumEerl
and am and have beea a bona fide resideet ot the State of Florida ~inee ~ ~'~S ~ day of
~ ,19 . and I reside at ~U'`~ ~ k ~ ~
~ (&re~t IZamEer)
j~~~~~ _ ST. LUG I E County. Florida,
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and this statemeat is to be taken u my declanUon of citiunship~ actual iegal residenee and domicile in the State ot Florida.
~ IF fOR THE PURPOSE OF ENROLLING IF FOR HOMESTEAO PURPOSES~ !
CHILDREN IN SCHOOI~ PIEASE STATE PLEASE CHECK: r~/ ~ '
T H E 1 R N A N E S: j_~,G._J
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. SZ LtIC1E ~1)NT't
IiOCf i? P'vitR~S
~tERK Lt;iCWt COUR7 t,~
RECORD YfRIFIED
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324105
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{ I FURTHER CERTIFY that I will cegister at my local address when the registration books reopen. and comply with all
~ other requirements of s legal residenl of this State.
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~ I FURTHE~ C~RTIFY that I have no intention to return to my former domicile, and I intend to remain in
T~ ~ ~ S T. L U C I E . County.
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Florida. permanen~i; .
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~ Swora,~,q~.sut~Cribad~tore me this day ot ~ /[..~?c~ ~
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- t. z.-~~c . A.D. l9 76
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~ ER P01 TRAS LERK OF C IRCUI T COl~2T .
~ ST. LUCIE COUNTY, FLORIUA
~ BY : ~ ~ ~/~~y/
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EPUTY LERK B~~
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