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Declaration of Domicile and Citizenship
X36642
TO THE CLERK OF THE CIRCUIT COURT. .
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ST, LUG 1 E _ COUNTY, FIARIDA:
Th4 i my declaration of Domkik and Citizenship in the State of Florida that I aln Sling thL day in secordanoe. and in .
conformity with Section 222.17, Florida St~atwut_es.
Chi (1 f e ~ I ,
1 was former a legal resident o[ _ - - ~
lCltyl 1lhate) 1
resided at . However, I have changed aly domicl~e to -
l8treat and Numbarl _ `~C
and am and have been a bona Sde resident of the State of Florida since '1 ~ of
1) i .
N la. ~ (iY 1 _19~~. and I reside at u o g I a s m 1 n.~e ~ V~ ~ ~
(8terat and NumDar) 1
f~.l y~ P~- ~i(~t _ ST. LUG I E County. Florida.
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and this statement is to be taken as my declaration of citizenship. actual legal residence and domia7e_in the State ~ Florida.
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R THE PURPOSE OF ENROLLING IF FOR HOMESTEAD PURPOSES, -1
IF FO
CHILDREN IN 3CHOOl, PLEASE STATE PLEASE CHECK:
THEIR NAMES:
i~EO Afl':; RECOROEO~
„V••TY Fl_~. i 3
_ 'ate':~
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I FURTHER CERTIFY that I w111 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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j I FURTHER CERTIFY that I have no intention to return to my former domicde. and I intend to remain in
T I U C I E _ County.
1(Styl ~ i
Florida. permanentl,-.
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rum. t.
J~~t C~U~T`'~
fC~UNTY,fI~~
lI3am~l
~ to JC~SmIn~ ~~er~u~ _
IAddrepT
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Sworn to and subscn'bed before me this day of .1/ 1 ~C ~ 1Y •
l . A.D.19_ 79
e ROGER POI AS CLERK OF C f RCU 1 T COURT
ST. LUGlE COUNTY, FLORIDA -
BY:
EPUTY IERK
soo!~ ~4 ~c~2187
4G(1 Firm 71 22