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Declaration of Domicile and Citizenship
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TO THE CLERK OF THE CIRCUIT COURT.
ST. LUG 1 E COUNTY, FLORIDA:
This is my de=laration of Domict7e and Cltiunship In the State of Florida that I am Qling this day in aeeordanoe, and in
conformity with Section 222.1?, Florida Statu
I was formed a legal resident of aad I
tc~y) IStatd
resided at - 4 Y ~lG' ~ . However, I have changed my domicile to
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and am have been a bona fide resident of the State of Florida since ~~r~ dKy of
- ~ . 19-!?
- and I reside st ~ ~ ~ • ~ ~ ~ ~ ~
(8trNtasdNnmbar)
S T . LUG 1 E County, Florida.
lpty)
and this statement is to be taken as my declaration of eiLizenship. actual legal residence and domicile in the State of Florida. •
IF FOR THE PURPOSE OF ENROLLING IF FOR HOMESTEAD PURPOSES,
CNIIDREN IN SCHOOL, PLEASE STATE PLEASE CHECK:
THEIR NAMES:
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._~J t.N:~ ~ECORCED
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~ I FURTHER CERTIFY that I wdl register at my local address when the registration books reopen, and comply with all
other requirements of a legal resident of this State.
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~ I FURTHER CERTIFY that I have no intention to return to my former domicile. and I intend to remain in
j T. U C I E County,
ICky) _ s
I Florida. permanenti;.
C> i ~t . ~ t CA
.r,~ .y aP
~ COUkT~•S~
(Address)
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a Sworn to and subsen'bedf beflore me this day of
f~/1 - A.D.19_
79
ROGER P01 TRAS. CLERK OF G IRGUI T COURT ~
ST. L IE GOUNTY, FLORIDA - .
BY: «
EPUTY LERK
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