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Declaration of Domicile and Citizenship
4~55'7S
TO THE CLERK OF THE CIRCUIT COURT.
ST . L UG I E COUNTY. FLORIDA: .
This is my decluation of Domic~7e and Citiuaship in the State of Florida that I am filing this day in accordance. and in
conformity with Section 222.17. Florida Statutes.
I was formerly a legal resident of P Rx ~ ~ r7 and I
1(.5tr) IState)
resided at ~ f / S % . However. I have changed my domicile to
IStrest sad Number)
and am and have been a bona fide resident of the State of Florida since ' ~ ~ day of
J .19~. and I reside at 7~~ •-S r~ / ~'L~ ~S L ~ ;'S / ~J
(8tee~t sad Number)
-~T' ;7~ ,t _l_%(' i C3. ST. LUG I E
. County. Fbrida. `
ICit71
and this statement is to be taken as my declaration of citizenship. actual legal residence and domicile in the S4te of Florida.
IF FOR THE PURPOSE OF ENROLLING IF FOR HOMESTEAD PURPOSES,
CHILDREN IN SCHOOL, PLEASE STATE .PLEASE CHECK:
THEIR NAMES: ~
'9~9 N,aY 24 P~, 2~ ~ _
FILED REENO REGGkOEU
S ROGER
POI7RA~A•
CLERK CIRCUIT LOUR
RECD.°.tl ~~;-p~:
4455'75
I FURTHER CERTIFY that I will register at my local address when the registration hooka reopen. and comply with all
other requirements of a legal resident of this State.
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.
t (City) _ } .
Florida. permanents; .
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(Name)
1Addreee)
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Sworn to and anbsrn'bed before me this _.r.~' day of ,'-l% _ ~l i~
s~
~ L ~ A.D.19_ ~l
ROGER P01 TRAS. LERK OF G IRGUI T COURT
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~ ST. LUG I E COUNTY, FLOR 1 DA ~ .
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EPUTY LERK
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