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TO TILE CI.E1tK OF T11E CIRCUIT COURT,
ST . L UC I E COUNTY, FLORIDA:
This is my ~eelaration of Domicile and Cilizonship in the State of Florida that I am Ctling this day in accordance. and in
conformity with Section x.17, Florida Statutes. .
I was formPrl a legal resident of G R ~ ~ ~ ~ ~ h ~ y ~ I
ICityl (State)
resided at ''T 7D 2 A,eG ~L ~ - However, I have changed my domicile to
• t8trset and Number) ~
and am and have been a bona fide resident of the State of Florida since ~ day of
-19 - and I reside at ~ ~ ~A
dS~/o/? lam- ~~l ~ a ~ ~ t
- - (8treet sad Number)
P ~ ~2LC r- ~ ~ ST . lUC I E County, Florida,
tCit~l
and this statement is lobe taken as my decluation of eitizership, aMual legal residence and domicile in the State of Florida.
IF FOR THE PURPOSE OF_ENROLLING IF FOR HOMESTEAD PURPOSES, v
CHILDREN ~IN SCHOOL, PLEASE STATE PLEASE CHECKS r?1
THE 1 R N A N E S S ~~---~-,--fit
- r CDRD~`D
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I FURT1iER CERTIFY that I will register at my local address when the registration books reopen. and comply with all
other requirements of a Icgal resident of this State. _
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I FURTHER CERTIFY that I have no intention to return to my former domicile. and I intend to remain in
T. U G 1 E .County.
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i
Florida, permanenti; .
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o (Addreu) v
Sworn to and subscribed beture me this ~
day of ( ~ ~C `L 3 3 ~ S
~ -
- A.D.19_
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ROGER OI TRAS, CI_ RK OF CIRCUIT COURT
Y)
ST. LUC I E COUNTY, F<_OR t UA "
BY : Q~/ 1°
UTY LERK
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`~l1 1571
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