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Declaration of Domicile and Citizenship
4:36'753
TO THE CLERK OF THE CIRCUIT COURT,
ST. LUC 1 E COUNTY, FIARIDA:
This is my declaration of Domicile and Citizenship in the State of Florida that I am filing this day iA accordance. and in
conformity wrath Section 222.17, Florida Statutes.
I was formed a legs) resident of ~ ~ wif~< / ~ Ss" and I
late) ~ IStat.)
resided at y~ ~~~d ~.F~ ~~!rf . However. I have changed my domicile to
(Strut and Numt+~r)
and am and have been a bona fide resident of the State of Florida since ~ day of
,19._: and I reside at : ~ S'~ k J~RaN~/110 R~ -
(Street and NumDar)
~pa~- S'T ~ d u,E ST , l UC I E County. Florida,
tat,)
and this statement is to be taken as my declaration of citizenship. actual legal residence and domicik in the State of Florida.
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IF FOR THE PURPOSE OF ENROLLING IF FOR HOMESTEAD PURPOSES,
CHILDREN IN SCHOOL, PLEASE STATE PLEASE CHECK:
THEIR NAMES:
4:36'53 i
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I FURTHER CERTIFY that I will register at my local 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 ao intention to return to my former domicile, and I intend to remain in
T, U C I E County,
~ ICitT)
Florida. permanently .
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Sworn to and subscr'bed before me this ~ ~ day of ~ '~.1 V~~ -
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~~ll~ ~ , A.D.19_
ti 79
ROGER P01 TRASH CLERK OF CIRCUIT COURT
ST. I E COUNTY, FI.OR UA
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EPUTY L.ERK
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