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Declaration of Domicile and Citizens p ;
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TO THE CLERK OF THE CIRCUIT COURT.
ST. LUG i E COUNTY. FLORIDA: }
This b my declaration of Domkile and Citizensbip in the State of Florida that I am filing this day in accordance. and in
conformity with Section 222.17. Florida Statutes.
I was formed a legal resident of Lw.oE~o~~ and I
(City) (Blatt)
resided at / ya 9 ~ . However. I have changed my domicile to
lSteett and NumDa) '
and am and have been a bona fide resident of the State of Florida since ~9-s~ day at
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~•4i~ . / .19~~ and beside at ~'yo~~ G,o~.u~1~0 /1vE~vE ~ t
(StreN and Numbar) ~
r-?- ~it`~'e~- ST. LUG i E County. Florida,
(GVI i
and this statement is to be taken as my declaration of citizenship. actual legal residence and domicile in the State of Florida.
IF FOR THE PURPOSE OF ENROLLING IF FOR HOMESTEAD PURPOSES,
CNILOREN IN SCHOOL, PLEASE STATE PLEASE CHECK:
THEIR NAMES2
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I FURTHER CERTIFY that I will register at my 1oca1 address when the registration books reopen. and comply with all
other requirements of a legal resident of this State.
I FURTHER CERTIFY that I have no intention to return to my former domicile. and I intend to remain in
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~ Florida. permanencl;. s
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Sworn to and subscribed before me this day of - -
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ROGER P01 TRAS. CLERK OF G 1 RGU I T COURT
ST. LUGIE COUNTY, FLOR1 A .
BY: -
EPUTY t.ERK
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