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Declaration of Domicile and Cit~zensh~p
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TO T1iE CLERK OF THE CIRCUIT COURT,
ST. Lt1C i E ap~y. ~,p~~: _
Thia l~ ay? deelualioa ot Domlcile and Citizenship ia the State ot Fbrida that I am tiling this dqr in aecordaaca. and in
eoaformity with Section 222.17. Florida Statutea. .
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I wu [or~ a legal re~idant oi ~ aad I
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resided at l Pn~+ ~~.,.X~,~lcQ:~- . However. I have ebanged mr domicile to
IStiwt wd Nua?bK) .
and am and heve baea a bon~? fide resident ot the State oi Florida since day ot
~~CQ,~rn~.19 7
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_ and I reside at y V ~ ~
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~ a~ p , S T. l UG I E Couucy. ~a
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~ and this atatement is to be taken aa my declaratioa of titlzenahip. actud iegal residenee and domicile in the State ot Florid~.
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• IF FOR THE Pt1RPOSE Of ENROLLING IP FOR HOHESTEAO PURPOSES~
CHIL~REN iN SCHOOL~ P~EASE STATE PLEASE CHECKS
THEIR NAMES2
fILED ANp RECOROED
- St. LUCIE COUNTr FLA.
~L RKCCIRCUIT COURt ~
RECORD VERrf!f0.~ ~
~ l 12 Ze PH'~6
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I FURTHER CERTIF'Y that I will register at my local address when the registration books reopen. and comply with all
other requirements of a legal resident of this State. -
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! I FURTNE~ CER I that I have no intention to return to my former domicile. and I intend to remain in
~.ct.w~cp ~ ST . L U C 1 E . County.
i (Cit~? _
; Florida, permanen~i~ . ~
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s _ ,S- t., ! cGit• ~ (Name)
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G ~ ,i.. - : . (Addeeaa)
? 5~v' t.aoc~ subscfi1s~1'hetore me this day of 7 3 ~
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{ ~ ~.t-- , A.D.19 76
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~ R :i~Of.TRAS CLERK OF CIRCUtT COU2T
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k ST. LUCIE COUNTY, FLORIUA
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- _ . EPUTY LER~
F , EtQ~ ~:JJ PAGE ~
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