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Declaration of Domicile and Citizensh~p ~.,F
.436~00
7'~ THE CLERK OF THE CIRCUIT COURT.
ST. Ll1C t E CpUta~r, FtARtnA:
This is my deeluatioa of Domic~7e and Citizenship ia t6e State of Florida that I am 61ing this da,p in arcordance. and in
cwnlormity witA Seetion 222.17. Florida Statutes.
I was tormerl a tegal resident ot W~slh~ 11 • and I
l(~t7) IStal~)
resided at 3~0«y /9.~n~s G 9 n e. . However. I have ehanged my domic~e to
(3trsat aad Nomb~tl
and am and have beea a bona fide resident of the State oi Florida since a' ~ 9 aU' ~ ,
~.C ,19~~. and I reside at Z 2. 9 c T<<t :
(Stre~t aad Numbrl ;
~e~ ~S/': c~ Q ST . L UG I E Count~, Flor;da,
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and this statement is tto be taken as my declaration oi citiunship. actual legal residence and domici7e in the State of Florida. ~
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I.F POR THE PURPOSE OF ENROLLING IF FOR HOMESTEAO PURPOSES~ {
CHILOREN IN SCHOOL~ PIEASE STATE PLEASE CHECKS ~
THEIR NAMESL
' c:~ Fr~ t,R;~ RECOR'JEb' t
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; I FURTHER CERTffY thst I will register at my local address when the registntian books reopen. and comply with ali
~ other requirements of a kgal resident ot this State. '
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I FURTHER ~ CERTIFY that I have no intention to return to my former
d~i1e. and I intend to remsin in
, T. ~ _ County.
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~ Florida, permanencl; .
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Sworn to and subscribed before me this ~ day of ~o ~ j~ c i t_
~ ~a~ 79 .
° A.D.19_
2
~ ROGER P01 TRAS~ CIERK OF C I RCU I T COl~2T
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~ ST. LUGIE COUNTY, FLORIUA
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~ BY: '
EPUTY LERK ,
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