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Deciaration of Domicile and Citizenship ;
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TO Tll~ CLF.RK OF TffE CIEtCU1T COURT. .
ST. LUC I E cocr~r, ~.o~nA:
This is my declaration oi Domicik and Citizenship in tbe Stste of ~'lorida that I am tGng this dar in accordance. and in
eontormity with Scction 222.17. Florida Statutes. ~ '
I was tormerl :legal resident ot _ GA ti'.~ ~ N ~/7 ~ /~F y~' /Q ~ and I ~
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resided at ~~E ~ S~~ R 7' f~ ~'F . However. I heve ehanged my domicitc to ~
(Stneet a+d Nnmpe~)
a~d am and ha~e been a b~na Gde resident o[the State of Florida since dsy of
/r'F .19~. and 1 reside at _ / 02 ~v19 /V O S
(Str~eet ~nd NumDerl
_PD/~ T" oS~ UG' /F ~ ST. LUG 1 E ~ County. Florida, ~`lSY
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and this statement is to t?e taken as my dc.~cla~ation o[ titi~enship. ectual tegal residence and.domicile in the Stnte o[ Florida.
IF F'OR 711E Pl1RPOSE Of
ENROLLI~:G If FOP, NOHESTE4D PURPO~ES~
CHILOREN IN SCHO~L~ PLEASE STATE PLEASE CNECK: ~
THEIR NAHES2 j ^ ~
' fiLEO AND RECOjDED ,
- ST.IUCtE COUMTY F~A ,
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Ocr 3 10 s9 AM'1~
4189`76
I FURTIIER CER'fIFY that I will rrgister at my local address when the registration books reopen, and comply with ail
other rcquirements oi a legal resident of this State. ~
I FURTFIF.Z CE:RTIF'Y that I havc rto inteation to reinrn to my f~rmer domicile. and I intend Lo remain in
T. U~ C
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E Caunty.
(Cit~1 . ~
Florida, pcrmanenti~ .
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Sw•orn fo and subscritx,d Fie[are me this ~ day ot / ~~1 ~-`c~ ~J~ ~~y r~
~ . A.U. 19. 7 ~ - -1 r ~
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ROGER P01 TRA~,
CLERK OF G lRCUI T COI~tT
ST. LUCIE GOUNTY, FLOF2IUA -
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BY. ~
EPUTY LERK ~ €
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