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Declaration of Domicile and Citizenship
TO THE CLERK OF THE CIRCUIT COURT. 4`tI~~.QOt7
ST. LUG 1 E COU~Y• FIrORIDA: -
This is my declaration of Domieik aAd Citizenship in the State of Florida that I am filing this day in accordance. and in
conformity with Section 222.17. Florida Statutes. ~r
I was formerly a legal resident of .o fl~_,(~ ~t iS L L- ~ / and I
!City) (3tate)
resided at 1 Z. U 4 M rt N c i~ A However. I have changed my domie~e to
18tre~t and Nnmbar) _
and am and have been a bona fide resident of the State of Florida since T ~ day of
NC y~ M ~3 t%!t ,19Z and I reside at ~ D / W . L ~7 O/4C /f i D C s3 .r/t
IStnat and NnmDer)
FT r~iC2 c ~ ~ ST . L- UG I E county
1(~ty)
and this statement is to be taken as my declaration of citizenship. actual legal residence and domitile in the State of Florida.
IF FOR THE PURPOSE OF ENROLLING IF FOR HOMESTEAD PURPOSES,
CHILDREN IN SCHOOL, PLEASE STATE PLEASE CHECK:
THEIR NAMES:
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''~i I FURTHER CERTIFY that I wt71 register at my local address when the registration books reopen, and comply with all -
other requirements of a legal resident of this State.
I
I FURTHER CERTIFY that I have no intention to return to my former domic~e. and I intend to remain in
T. U C I E ,County,
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Florida, permanents; .
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Sworn to and snhsen'bed before me this ~ day of T I~/E
/i' C L` , t c ,r4 3 j j/~ U
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A.D.19_ ~l - r
ROGER POI AS, CLERK OF CIRCUIT COURT
ST. L UG I E COUNTY, FLOR t DA
EPUTY LERK -
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