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Declaration of Domicrle and Citizenship
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TO THE CLERK OF THE CIRCUIT COURT,
ST. LUG 1 E
COUNTY. FLORIDA: .
This is my declantioa of Domicile and Citizenship is the State of Florida that I am filing this day in accordance. and in
coaforn~ity with Section 222.17. Florida Statutes. .
I was formerh a legal resident of I ~-I-1' / ~ and I
. ~ (Cityl l3tatel
resided at C~ ``"e . However. I have changed my domicile to
l3trest aed Number)
sad am and have been a Dona fide resident of the State of Florida since ~-~--e day of
19~ and I reside at r
ST. LUG i E Nomberl
County. Florida.
I(~t7)
and this statement is to be taken as my deeLration of citiaenship. actual legal residence and domicile in the State of Florida.
IF FOR THE PURPOSE OF ENROLLING IF FOR HOMESTEAD PURPOSES,
CHILDREN IN SCHOOL, PLEASE STATE PLEASE CHECK: rj"~~'
THEIR NAMES. ~ ~ 1
442,543
'79 ~ 3 Q A;'~ ' i? : 5 2
I FURTHER CERTIFY that I will register at my local address when the registration books reopen, sad 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 domicile, and I intend to remain in
T. U C I E County,
(City)
Florida, permanenti; . !
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CJ _ ~ _ ji to \ , ~ ~_.L%C-~-G
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F Sworn to and sabscn'bed before me this ~ day of
s ~
A.D.19_
. 79 .
ROGER POI TRAS, CLERK OF G IRGUI T COURT
ST. L UG I E COUNTY, F LOR t OA
1
BY: ~
~ EPUTY LERK '
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