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4:34935 •
TO THE CLERK O!'' THE CIRCUIT COURT, -
ST. LUC 1 E CovIVTY, FLORIDA:
This is my declaration of Domicile and Citizenship in the State of Florida that I am filing this day in accordance. and in
conformity with Section 2:.'2.17, Florida Statutes.
I was formed a legal resident ot. S • sad I
IlStrl ~ iState)
resided at ~~0 `~~i' ~1 l'v~ - However, I have changed my domieilo to
l&reet sad Number)
and am and have been a bona tide resident of the State of Florida since ~ ~~f ~6 dsy of
~ SDP ~ ~ BG vo - ~
,19_.L~ and I reside at 1_
18treet and Number)
~/f'T ~~CC / ST. LUC 1 E County. Florida.
ta~,l
and this statement is to be taken as my declaration of citizenship. actual legal residence and domicile in the State of Florida.
IF FOR THE PURPOSE OF ENROLLING. IF FOR HOMESTEAD PURPOSES,
CHII.OREN IN SCHOOL, Pt.EASE STATE PLEASE CHECKS
THEIR NAMES:
Flt_ED AND RECORDEO~~
~'••'-:,'C1~ ^t)t11'~TY, FLA.,
434935
'79 Jr; . 16 PM 12:3 0
J
I FURTIiER CERTIFY that I will mgister at my local address when the registration books reopen. and comply with all
other requirements o[ a legal resident of this State.
I F'URTIiE:t CERTIFY that I have no intFntion to return to my former domicil, and I intend to remain in
T. L u~ 1 t .County,
ten,)
{ Florida, pcrmanenti;.
i
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P
i ~ E`o (Name)
i ~jAddccaa)
day of 7~G'!i?~ r/£X ~F ~1. ~.3c,/.TV r
SK~orn t~ and subscritx~d Lafore me this
9
ROGER F'O I TRnS~ CLERK OF CIRCUIT COURT
ST. LUCIE COUNTY, FLORtUA -
' ~
BY: -
J2,c.J-c.~ tt
EPUTY L.ERK !
" P 3(li X402
6QGK jtf,F
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. AGQ Form 71 :2
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