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Deciaration of Domicite and Citizenship
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TO THE CLERK OF THE CIRC[)IT COURT.
ST. Lt1C 1 E CoUfvrir, FLORIDA: .
This is m~ declaration of Domicile and Citizeaship in the State oi Florida that I am fil'ing this da~ in accordance, and in
eonformity with Sectioa 222.1T. Florida Statutes.
1 was formerl9 a legal resideat o1 and I
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resided at . However. I have ehanged my domicile ta
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and am and have been a bona fide reaideat of the State of Florida since ~ day oi
.19 _ and I reside at 1 ~ ~~t t.t ~ ~1~ 1 Il J~,
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and this statement is to be taken as my declaration oi citizenship. actual legal reaideace and domicile in the State of Florids.
(F FOR THE PURPOSE OF ENROLLING IF FOR HOMESTEAD PURPOSES~
CHIL~REN IN SCHOOL~ PLEASE STATE PLEASE CHECK2 ~
THEIR NAMES2
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; I FURTHER CERTIFY that I will register at my local addres~ when the registration books reopen, and comply with ill
; other requirements of a legal resident of this State.
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~ I FURTHER CEBTIFY that I have no intention to return to my former domicile, and I intead to remain in
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~ Florida, permanenti; . ~ ,
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~ S.vorn to a snbsrn'bed before me this ~ dsy of C~ l`" , C~ J~~1
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~ A.D.19_ ~9 .
R06ER POi TRAS, CLERK OF G IRCUI T GOl~2T
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~ ST. LIJG 1 E GOUNTY, FLOR 1 DA ' -
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EPUTY LERK '
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