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TO Tllr: Cl.~:liK Ob' THE CUtCU1T CO~IItT.
ST.~LUC I E COUN1'Y. FI.ORIDA: 2
This is my declaratio~i ot Domicile and Citizenship in the StAto of Florida that I am filing this dey ia accordance~ and in
co~tormitY with Section 222.17. Ftorida Slatutcs.
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I K as formert s kgu! resid~nt ot e i ~ ,
. ~ (Citr) ~ (St~ts)
resided at ~C / . However~ I hnve c?u~nged my domicile to ~
(Stnet ~d Nuv?berl - /
and am and havc beeA a twna fidc resideAt of the Statce of Flocida since 1~ T~2 day ot ~
~ n ,19 7 - snd I reside at ~~•2 /q .ER/1t m ~ n S~':- ~
~ LS , (8treet wd Number) ~
~ c R c~ ~ ST . L UG I E County. Florida, ~
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and this statement is to bo taken as my declaration ot citizenship. actual legel residence end domicile in the Stu~e oi F'lorida. ~
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IF FOR 7HE PURPOSE Of ENROLIiNG ~ IF FOR,NOMESTEAO PURPOSES~ ~
CHIIDREN IH SCNOOI~ PLEASE S7ATE PLEASE CHECK: r~~]
THE 1 R NANES: k~~-J i
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I FURTHER CERTIFY that I will register at my local address when the rngistration books reopen. and wmply with alt
other requirements o( a Icgal resident of L6is Slate.
I FURTIiF. CE ' that I have no intr~tian to return to m former domicile. . and I intead to remnin in
. U C 1 E . County.
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S~vorn to and subscribed before me lhis day of ~„~,~c.~[j~S,~, ~
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~Olq~~~. . A.D. 19_ 7 / ; ~
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ROGER P01 TRAS, CLf_RK OF ClRCU! T COURT ,
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ST. LlK I E GOUNTY, FLC~R tUA -
BY:
^ E P U T Y ~ E R K ~OOK ~O~ i~GE t~VV
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