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Declaration of Domicile and Citizenship
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TO THE CLERK OF T'HB CIRCUIT COUAT.
ST. Lt1C 1 E ap~. ~,p~~:
This b my deelaratio~ of Domieile aad Ciiizcc~hip in the State of Fiotida that I ua G1ag this d:y in sooordanre. u~d in
eoafarmitr ~rith Section 222.17. F'lotida Statutes.
I w~as torme 1 a kga! resident oi . ~ ~ ' and I
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rssided at -~~-7 - 2--~~'~Cc'-~u_' - Ho~rever. I have clunged my domicile to
l8tt~t ~d Nomb~l '
and am aad bave beea a boaa Gde resideat of the State ot I~'lorida since - dar ot
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19~.5~,. and I re~ide at 'Z~` ~ ~ _/s::.~;~1ii~::t •'-~2`O '
(Sw~t and Numb~rl
~T . LUG I E CouAc~. Florida.
(av~
aad this statement is to De talcen as m~ dec4ntion ot eitizenship. actual kgal residence at~d domicile in tha State ot Ftorida.
If fOR THE PURPOSE OF EMROLLINC IF POR HOMESTEAD PURPOSES~
CHIIDREN IN SCHOOL~ PIEASE STAtE PLEASE C1IECKS r,-~
~HE IR NAMES: - ~
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34U1; ~s
FttfD aNis KE~OkpED
ST. LI;C+i GOUNTY FIA.
ROG~ - ~ )t ~ RAS
- CtFRR ~'^,C3tT COflRt
RECOR±t yE~f•,r,Er;
Ju~ 11 i0 07 AN'76
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I FURTHER CERTTFY that 1 will registcr at my locsl address when the registntion books reopen, aad complr witfi all
oiher requirements ot a legal resident of this State.
I FUR~i~3 ~FY that I have no intention to retum to my tormer domicile. and I intend to remain in
~ ~ ...CL , ST . L U C 1 E , County.
IC~t~1 .
Florida. permanenci, .
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' (Nams)
(Addr+a)
Sworn to aod~ubseribed beioce me this / day of
J . A.D.19 76
ROC~ER P01 TF2AS. CIERK OF C IRGUI T COl~2T
ST. Ll~? E COUNTY, ~~OR t UA ~
g,r3--~C I
- EPUTY IERK f
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