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Dectarat~on of Domicile and C~tizensh~p ~
~ 4:3'7245
TO THE CLERK OF THE CIRCUIT COURT,
S T. l UC I E COl1NTY. FIARIDA: .
This is my deelsratioa oi Domic~e and Citisenship,in the State of Florida that I am filing this day in aecocdanee. and ~u
conformity with Seclion 222.17. F'lorida Statutes.
I was formerly a legal nsident oi ~/p 0 W N S N'1 I L C- S and I
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resided at I y 5~ ISOI'S Ld f~ ~L d~ . However. I have ehanged rqy domic~e to
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and am snd have been a bona fide resident ot t~e Stste of F7orida sinoe 3 ~~'y ~ 7~ day of
,19 - and I reside at •3 a~ I M A7h 1 S
~ (gteeet ~od Nnmbsrl
~T-. S7- 1. 1~ ST. LUG I E Couaty. Florida, :
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and this statement is to be taken as my declaratioa of eitizenship. aMual legal resideace and domic~e in the State ot Florida.
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IF FOR THE PURPOSE OF ENROILING IF FOR HONEStEAO PURPOSES~
CHILOREN IN SGHOOL~ PLEASE STATE PLEASE CHECK: ~ t
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I FURTHER CERTIFY that 1 w~l register at my local address when the registration books reopen, and comply with aU
other requirements ot a legal resident of this State.
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~ I FiJRTHE~ CERTIFY that I have no intention to rnturn to my former domicile, and I intead to remain in
~ ~ 5 T. L U C ~ - l County.
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~ Florida, permanenci;.
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~ Sworn to and subscribed before me this day of -
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~ //LQit.~ - A.D. l9_ ~9
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; ROGER POI TRAS. CLERK OF G IRCUI T GOl~2T
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~ ST. Lt1C i E COUNTY, FLOR t UA
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~ • EPUTY LERK
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~ s~w 3U5 183
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~ AGn Fo: m 71 ~
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