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Deciaration of Domicile and Citizenship ~
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TC1 THE CLERK OF THE CIRCUIT COURT.
ST . L UG 1 E CpuNTY, I~'L.ORIDA:
This is m~ daluatioa ot Domie~e and Citisenahip in the State of Florida that l anr fil'~ng tbls dsy. ia accordana. and ia
contormit~ witb Sectlon 222.1?. Florida SLatuLes.
I was formerl a kgal resideat of w~ r~ . / v e.~ ind I
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resided at ~ 70 ~ 1~~ S~~ ~ - However. I have changed m,y domic~e to ~
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and am and hsve been a boaa Cide resideai oi the State oi Florida since - d~~ ;
_ 19~. andl nside at r o a I~ I O~f
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S T. l UG I E Count~. Florida,
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and this ststemeat is to be taken as my declaratioa ot eitizenship. actual legal residence and domiu7e in the State oi Florida.
IF POR THE PURPOSE OF ENROIIING IF FOR HOMESTEAD PURPOSES~ ~
CHIIOREN IN SCNOOI~ PIEASE STATE PLEI?SE CHECKS ~
THEIR NAMES'
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_ _ • _ ' ^U*2TY ~L::. l
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'79 FE~3 28 aM In : i T .
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` I FURTHER CERTIFY that I will register at my local address when the registratioa books reopen. and comply with sll '
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; other requiremeats of a legal resident of this State.
' I FURTHER CERTIFY that I have no intxntion to return to my former domicile. and I intend to remain in
~ T. U C 1 E ~ _ County.
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~ Florida. permanenti; .
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= Swora to and subscnbed before me this ~ dsy oi `
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? ROGER POITRAS CLERK OF GIRCUIT GOl~2T
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~ ST. LUG I E COUNTY, f LOR 1.OA
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~ BY: ~,~~eS~
~ FPUTY LERK . ~
~ ~ gecr ~U4 ?~4~.~ 323 `
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