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Declarat~on of Domicile and C~tizensh~p ~
441599
TO THE CLERK OF THE CDtCU1T COURT.
ST. L UG I E ~pv~y. ~,p~A: ,
This is m~ declaration of Domic~e and Citiunsbip in tl~e State oi Florida that I am 51ing this da~ in uoordance, and in
conformit~ arith Section 222.17. F7orida Ststutes.
I was formerly a legal raident oi ~(1( j~-~NT~A 1~~ ~ N_~. and I
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resided at ~ l1~5 K~m~ ~ v~, . However. I have eDanged m~ domie~7e to
ISt~+~at ~ad Namber) ~
and am and have been a bona fide reaideat of tbe S4Le of Florida since ~ da~ of
.19 ~
Q.. and I reside at 3 3~ ~ 1~E r1Q~-~~ .
18t:e~t aed Nombar)
~it rcP~ ST. LIJG I E ~~t~~
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and this statement is to be taken as my declantion of citi~enship. actual legal residence and domirile in tbe SLte oi Fbrida.
IF FOR THE PURPOSE OF ENROLLING IF FOR HOMESTEAD PURPOSES~
CHILDREN IN SCHOOL~ P~EASE STATE PLEASE CHECKS ~
THEIR NAMES. ~
V~1 i chaei -RQu.~ Slad ~ ~r.
P,~NN i e ~'Y10.r~ e~rQO~~ F!! R~CORDED'
. . - " ~~~;?Y. FL:;.
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; I FURTHER CERTIF'Y that I w~7! register at my local address when the registration booka reopen. and comply ~vith all
Mher requirements of a legal resident of this SLte.
i
I I FiJRTHER CERTIF'Y thst I have no intention to return to m former domicile. and I intend to remain in
T. U 1 E County.
E (at~~ .
f Florida, permanenu; .
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= Sworn to and subsenbed befon me this ~ day of ~ 3 C~ }l (~,l,l.C M~.
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~ ~ - A.D.19_ ~9 -
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> ROGER P01 TRAS. CLERK OF G IRCUI T COl~2T
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~ ST. Lt1G I E COUNTY, FLOR t OA ~ . ;
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~ BY S ~ " . . ~ ~
' EPUTY LERK '
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