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Deciaration o# Domicile and Citizenship i
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3241.~'~ ;
TO THE CLERK OF THE CIACUIT COUAT. ;
ST. LUC 1 E _ Cpvt~ry~ FI.ORIDA: ;
This b mp declantion ot Domicile aod Citizenship ia the State ot I~'larida tbat I aa~ Gting t1~.is dap ia aeeordance. and in
oontorn?itr with Scctioa 222.17. Florid~ Statutea.
I was tormerl a kgal resideat ot ~ I
t~7~ l8tatd
it ~ However. I have ehanged my domieile to
($teMt a~d N~~1
and am aad hsve beea a twna Cide resideet af the 3tate ot Florida since ~+r °t ~
/ --19~
`L.. aad I reside at •~02 ~o ~ _
~ ~ - ~ (8w~t aod Nam~
ST. lUG 1 E Cow,cr. Floriaa.
_ tabl ~
ltlld tA1S SLiLCQIQAt !S ~O ~ LikCil i! Al,r dECIaTi~1011 OI qljZlt47f11Q. actual kgd residence aad domicile in the State of Fbrida. #
~ If fOR THE PURPOSE Oi ENRO~LING IP FOR HOMESTEAD PURP~SES~
CHIL~REN IN SCHOOI~ PLEIISE STATE PLEASE CNECKt ~
THEIR NAMESL _
- ~
324i. ~
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- ~'tvc+~ co~nmr
fiOCER ?Ot~t ~
a~RK CI~~WT
RECORp YERiFtLO
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I FiJRTHER CERTIFY that I will register st my local address when the registration books reopea, and comply with all
~ other requirements of a legal resident of this State.
~
E I THE~ CERTIFY tiut I have ao intention to return to my tormer domicile. and I intend to remain in
~ i~~~~~ ~ ST . L U C 1 E . Couaty.
~ ~c~cr1 .
~ Florida. permaeentl; . \
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l.~'"•:' ,~;;_,;-~•r~ ~ (AddeeN)
~ Sworn``to ahd subscribed before me this ~ day ot ~~GZi 30~ 3~
~
~ ~ . A.D.19
76
~ GER PO I TRA . CLERK OF C I RCU I T COtJRT -
~
~ ST. LUGIE COUNTY, FL.ORiUA
~ BY:
PUTY LERK
. sa~~~~~ 861
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