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Deciaration of Domic~le and Citizenship
TO THE CLERK OF THE CIRCUIT COURT. 4~}9g
ST . L UG I E ~pvlvTy. ~-I,pxIDA: .
This is a>> deelaration of Domiu'1e aad CItiun~hip in the StaLe of Fiorida that I am filing this da~ in socordaaee. and in
conformit~ ~vith Sectioa 222.17. Florida Statutes.
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I wu formerl a kgal resident of ~D~~ ~ Cl . ~ and I
~ . (Cit~l (State)
resided at fl Vt5'~"~' . Ho~rever. I hsve ebanged my domic~e to .
~ IStreat aad Numba) ,
and am aad have b~en a bona fide nsident oitbe State of Florida since I~ ~7 ~
l
1~ ~R J~- .19~.. and I reside at _ 1 O hl ~ ~j2 ~~'/'l
e
q ,p (8tre.t aed Nombet)
`Ib2`}- -5~ 1 U c! L f f- ST . LUC I E Count~. Florida.
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and this statemeat is to be taken aa my decLntion oi c~tizen~hip, actual legal residenee and domic~e in tbe State oi Florida. ~
IF fOR THE PURPOSE OF ENROLIING IF FOR HOMESTEAD PURPOSES~
CHIIDREN IN SCHOOL~ P~EASE STATE PLEASE CHECKS ~
THEIR NAMES. •
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: 19T9 NAr~-1 P~t 12 54
SrlEO AE
C RECpRpEp . -
R~t~R POlTRAS~
CLER!( ClRCUIT COURT ~
RECORQ YERIFIfQ
I FUftTHER CERTIFY that I w~71 register at my local addresa when the registrstion books reopen. and comply ~vith aU
~ other requirements of a legal resident of thii State. -
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~ I FURTHER CERTIFY thit I have no 1l11,e[lt.l00 to return to my former domie~le. and I intend to remain in
~ T. U C 1 E . County, .
6 IG~t~) . ~
s .
~ Florida. permanenti~ :
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~ ~ - COUNl ~
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`GC~F
QWITY
~`O~ (Name)
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~ (Addrs..)
~ S.vorn to and anhxn'bed befon me this day of ~
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. A.D.19_ ~9 -
~ ROGER P01 S. GLERK OF G IRGUI T GOl~2T
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~ ST. LUG I E COUNTY, f LOR i D ~ . ~
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~ BY.
~ a ,
~ EPUTY LERK ~ ~
~ OR ' . _
~ ~O PAGE 9~ ~
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