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Deciaration of Domicile and Citizenship ~
- 32412~
To ~E cc~x oF ~~e c~curr coux~r,
ST. LUC t E ~ aputvTy~ E'I,ORIDA:
,
Thia is my deelaration ot Domicile and Citizenship in ths State ot Ftorida that I un Gliag this day in sccordance. and tn
oontormitr ~rieh Seeeioa 222.17. Fbrida Statutes.
I~ru tormerl a Icgal resideat of Ta? ~ ~11~~ and I
~cxy~ le~c.)
s~ ~ ~s~c~ ~ However. I have ebangcd my domicile to
lStiwt aed Num~d
ind am aad bave beea a bons C~de naideat ot the State o[ Fiarida sinee ~ ~ ~7 ~
19.~~ aad I reside at ~d 7
. (&e.~t aLd Nnmb~r)
ST . L UG I E
lCit7i
and this statement ia to be takea as my declaration ot eitiunstip. adual kgal residenee and doneieik in the State oi Fbrida.
• If FOR THE PURPOSE OF ENROLLING Ii FOR HOMESTEAD PURPOSES~
CHIIDREN IN SCHOOL~ PLEASE STATE P~EASE CHECK:
TNEIR NAMESt
- ST~WCIE COUMYY ftA.
CLERK CI3CU T C URT ~
• RECORD VERI~IEO ~
, - ~N S IO 18 AM'7`
' 32412~
j I FURTHER CERTIFY that I will register at my local address when the registntion books reopen. and comply ~?ith all
~ other requirements of a legal tesident o[ this State.
i
E
I E TIF'Y that I have oo intention to return to my tormer domicile. and I intend to remain in
~ 'o)~~ , ST . L u C 1 E , Connty,
i lCit7) .
~ Florida, permanenci; .
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~ SworxCtp~d s~ti~b~dbefore me this S day of '
~ . ( E
~ ~uc ~r~ , A.D. 1976
~ ROGER P01 TRAS~ CLERK OF C IRCUI T COURT
~
ST. LUGIE COUNTY, F~ORIUA
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~ P UT Y L E R K ~O`~ FAGE ~v~
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