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~ Deciarat~on of Domicile and Citizenship y ~
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TO THE CI~EAK OF THE CIRCUIT COUAT, 334 4;~
ST. LUC 1 E ~p~. ~,p~~:
TAis is mp decluation of Doanjcik and Citisenship In the Stats ot Florida that I sm t~ing tAis day ia aeeordanoe. u~d tn
contocmity with Sectioa 222.1T. Florida Statutes. . ~ •
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I Mas fonrie~ls a bga! resident ot 'e G~~ ~ .4 • and I ~
ICWf 1 ) ~
resided at ~~f~~ ~ c~ T~ . Harover. I bave ehaegad mp docnic~7e to s
l8ti+~t aud NumbKl . '
aad an? and have beea a botu t'ide c+esideat oi the Stata ot F'lotida since ~ T y dar ot ~
~.Q~ '.19~.~. aad I nside at ~ 6~! 2~,~ _S
IStM.t a~d Nmsb~.)
_.~'e e~ c~c , ST. LUG I E CouAcy. ~s.
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aad this statement is to be taken as m~r declantioa ot eitjzenship. utual kgal residence aad domieile ia tDe State ot Florida. '
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If POR THE PURPOSE OF ENROIIING IF i0R HONESTEAO PURPOSES~ ~
CHtt~REN IN SCHOOL-~ PLEASE STAfE PLEASE CHECK: ~
'~THEIR NAMES:
TA~~,~ ~,T ~1~~~~/,~~p„~'~v.-~~o,~~ .
f11EC Ayi~ R~G3RUF0 ~
St l.',;~;E ~ciL'NTY flA.
~ ~:,Er. ~ u 'da$
' C~faK C~-:.~~•T COURT ~
- ~c"~R'1 y,: •c E,
~ Mar ~10 10 si AH'~6
.33~4.i~~
~ I FURTHER CEftTIFY that I will register at my local address when tbe registntion books reopen. and aomply ~?ith all
~ other reqairements of a legal resident of this S~te. -
I
` I FURTHE.~ CER~IFY that I have no intrnlion to return to my former doanieile. and I IAtCIId to remain iw
~ jc~,< f'~r-~° , ST . L uc ~ E , County, .
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~ Florida. permaneati; . .
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a Sworn to and subscribed before me this ___1_S~ day of
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~ A.D.19 76
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~ ROGER PO TRAS, CLERK QF CIRCUIT GOU2 ~
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~ ST. LUGIE COUNTY, FLORIUA _
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~ BYs ~ ~ •
. ~ _ EPUTY LE -
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E AC(1 Forrn 71 22 ~