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Declarat~an c~f D~m~cile a~nc~ C~t~z~nsh~p~
42t?344 '
TO TIfE C1.E:Rti QF T11E CIRCUIT COUBT. ~
.riT. l_ (1G 1 E COUNTY. F I.~RIDA:
Thu is m~ dccta~etion ot Damicilc and Citvenship in tho State ot F{orida that I am Ciling this day in eccordAnce. and in ~
contormity a~ith Section ~1.17, Florids Statutes. ~
1 wt?s form~rl~ s Icga) nsidcnt ot ~
r~ ~'~C1.1 f t~~ t~ _ ~ ) i~ and I ~
~ ~ (Cityi lState) ~
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resided at _L_7~ ~I ~ r.!e ~~n ~ GC , i~owcvcr. I have changed my domicile to '
(Stnet and 2VumDrr) i
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and t+m and h~~ e bcen a bonA fide resident of t hr St~te of ~'iorida sinre ~~~t - day of ~
. ~
C ~
~'?~~.~d , ,-~?l~ ~~~~c~ ~~a. C' . . ~
, 19~~. and I reside at
~ (Street ~nd t~umt,rr)
, S, L.t C 1 F- ~ ST. LUC I E County, FloriJa,
ICi?rl .
and this ~tatement i.s to t,e txken as my decilration ot titizensi~ip, nctual legal msidence and domicile in the State of Florida. ~
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IF FOR THE PUF.POSE OF ENROLLING If fOR ItOHESTEAQ PUkPOSES~
CNILOREN !f: SCFtOOI~ PLCASE S?ATE . P~EASE CHECK: ~
THEIR r~I.MES:
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1 4lt0 Al1D !1E~?~~ ~ s
S? l~C~t GOyN Y ~ .
FOC€a'Q?IR~E ~
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pct Ig ~rQ~'T~
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I FUItTIiE[t CFRTIFY that I wilf register at my loral ac~c~ress when the registration books reopen, and corr,ply with all {
othcr mqLirements ai a lcbal residertt of this S,ate.
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l tl1RT13F,;t CFRTIFI th~t I ha~c no intention to return to my torm~r do:r.i~ile. t~nd I intend to remain in ' s
~ ~ T. U C 1 E County, ~
(Citpl . ~
Flosida, permat,cn~i: , ~
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'`~a *E j~.u--`.='~~o~ ~ J[' ,~,4 E~t f d_ , rf.~~ s.
c/f ~CUNTY.~~~p ~
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c'~ Y' [ fLt1.IX l°~ " i
(Addree~) ,
Sw•orn to an~l subscrihed hefore me this ~ day of ~%7 ~C~^ ~~~7,- ~-'~.Q ~
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~1:. ~ . A.D. l9. I S . ~
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ROGER POI TRAS~ CIERK OF C IRCUI T COU2T '
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ST. LUC I E GOUNI'Y, fLOFt 1UA ~ }
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