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TO TIIE CGEItK Ob' TIIE CIRCUIT COURT, ~
ST. LUG 1 E COUNTY. FIARIDA:
This is my declaration of Domicile and Citizenship in the State of Florida that I am Cling thin day in accordance, and in
conformity with Section 222.17, Florida Statutes. .
I was formerl a legal resident of ~ R - ~ and I
~ry?r) _ / (State)
resided at ~?f=3~ 3~ S " ~7 ~ ~~;'~N--- _ However. I have changed my domicilo to
(Street sad Numbs)
and am and have been a bona tide resident of the State of Florida since /D ~ ~ day of
-19 - and I reside at ~ /!/.~~/L'~a ~`P
_ (Strut and Number)
~r~ ~L ;11 ~q _ ST. LUG 1 E County, Florida,
lCit71 -
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile is the State of Fbrida.
IF FOR THE PURPOSE OF ENROLLING IF FOR HOHESTEAO PURPOSES,
CHILDREN IN SCHOOL, PLEASE STATE PLEASE CHECK:
THEIR NAMES.
- 412'73
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.
_ ~ t-:: _ _ _
I FURTHER CERTIFY that I will register at my local address when the registration books reopen. and comply with all
other requirements of a legal resident of this State. •
I FURTHEZ CERTIFY that I have no intention to return to my former domi.~ile. and I intend to remain in
i J T t_ u c, i t County.
(At71
f Fbrida. permanenti;.
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Gc~F ~ou~riv , f~°P !dress)
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Sworn to and subscribed before me this ~ day of 21 - J ~ ~~~e~~- `3`3
-,~9 -
.A.D.19_
ROGER POI TRASH CLERK OF CIRCUIT COURT
ST. LUG I E COUNTY, FI.OR 1 UA
gY:
• EPUTY LERK ~ r) ~ i
i.,: .
~ AGO E'orm 71 :'2
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