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TO TI IE: CLl•:RK OF TILE CIRCUIT COIIItT~
ST. LUG 1 E COUNTY. FLORIDA:
This is my declaration of Domicile and Citizoaship in the Stato oI Florida that I am filing this day in accordance. and in
eonfonnity with Section 422.17. Florida Statutes. -
1 was tormr~ a legal resident of t8~1
{City)
/G a- /~.jlL/n/ ~!/PG~C-tom ~ . However, I have changed my domicilo to
rosidcd at
(BtreN and Numbed _
and am and have beeA a bona fide reaidenl of the State of Florida since ~ V day of
l
~ -19 ~ ~ind I reside at ~ D ~ o ~ ~ ~ ~
l8treM sad Number)
ST . LUC I E - County. Florida,
latrl -
and this statement is to be taken ass my declaration of citizenship. actual legal residence-and domicile in the State of Florida.
IF FOR THE PURPOSE OF ENROLLING IF FOR HOHESTEAO PURPOSE ,
CHILDREN IN SCHOOL, PLEASE STATE FLEASE CHECK:
THEIR NAMES: -
' -FLED aND RECOD~
' ST, t_UCIE COUNTY; FLA::
=<~.COR[? VERIFtEO
43?613
- ~ '79 FEB I AN I i : 18
- iZOvi`k ~'OtTR~~
, CLERK CIRCUIT .COURT-
IFURTHER CERTIFY that I will register at my local address when the registration books reopen, and comply with sU
k
{ other rcyuirements of a legal resident of this State.
i I FURTIi R CERTIFY that have o intention to return to my former domicile. and I intend to remain in
~ T. U C I E - .County.
(City)
Florida. permanents; . -
i
V: '~G
.a , y
IName)
r / y/ o a- i4- _
t • ~ - - (Addroaal
SK•orn [nand subscribed before me this ~l____. day of ~ ' ~j 7
- -
F~ ~ v ~4 ~ . A.n. I9_ .
ROGER POITRAS, CLERK OF CIRCUIT COURT .
_ ST. lUG1E COUNTY, FLOk1UA
BY: ~a~~
E P U T Y L E R K b@0!( ~O~ 17 V 4 -
Lr •~i,(
~,~,n . .
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