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~ Qeciaration of Domiciee and Citiz~~ship
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TOT~IE CLERK OF TIIE CIRCUiT COURT.
ST. L UG 1 E ap~~ ~,p~DA:
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Tbb b my decluation ot Domtcile ~nd Gtitiscaship ia the State ot Florida tha! I am fillna thts dpr in ~ceordance. ~nd G~
~oafonaity with Section 222.17. Florida Statutes.
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I was fo~ a lega! resident ot ~ ,
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resided at ~ e : Q - Howrever. I have ehange~ mr domia'le to
IStr«e sad Nume.r) •
aad am aad bave been a bona Gde :
rai~rai ~+f !he State ot Florida sinee day ot
~ , . f ,19.Z(,,,. wd I reside ~t f ~ ~ ~l r7er ~--c._
i (StrMt wnberl
~o°'~ ,C ~ ST. lUG I E County. Fiorida.
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and th~ statement is to be takea aa nq dee4ration ot eitiun~hip. actud kgal nsidenee and domicile in tha State of Floride.
Ii fOR THE PURPOSE OF ENROLLING Ii POR HOHESTEAO PURPOSES~
CHILOREN IN SCFtOOI~ PLEASE STATE PLEASE CHECKS ~
tHE ! R NAMES:
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F~~E~ ~NO RECOROEO
ST. WCIE CO!lNTY F~ "
CLERK C:RCUIT COtlRT ~4~
RECORD YER1ilE0..~,~~
. N011 Z2 9 ~1 ~'76
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i I FURTHER CERTIFY that I w~ll register at my Mul nddrea~ wben the registntion books reopcn. aad eomply witb aU ;
j other requiremeats oi a legal resident of this State. -
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k 1 FURTHE~ CEBTIFY that I have n~nten on to return to my former domieil~`. and 1 intend to remait~ in
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.t ~.:1~ ~n f~~ ~ ST . L U C I E . Countr, !
i ItSt71 .
~ Florida. permanenti~ .
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' Sworn to ~nd sub~eribcd bc[orc me this ~'Z' day ot ~
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' ~ ~~(~n~~~'? ~ A.D.19 76
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; .ROGER PQ I TRAS, CLERK OF C IRCUI T COU2T
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~ '"ST. LUC I E GOUNTY, f ~OR 1 UA ~
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. UTY LERK F~n~r~VU F'Ct Ue~~!
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