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Declaration of Domicile and Citizenship ~
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~ ~ 454U31
TO T~ CI.ERK OF THE CIItCUIT COURT.
ST. LUC I E opv~. ~,p~~: .
T1~is is m~ deelaratjon ot Domic~e aad Ctti:enship ia the State ot F7orida tbat I am IDina tLia da~ in aooordanos. and ia
ooatorwit~ wkh Sectiao 222.1?. F'I~sida StatutAS. . -
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I was former a kgal r~esident ot L'nP,T? 1-~^E and I
((~It71 18tat~)
resided st Howaver. I bav~ ehaaged m~ domie~7e to
lBtaNt asa NomD~) • -
aad am and Mve beea a bona Sde residsnt at tbe Stata ot Fbrida sinoe ds~ d
- -19_~andIresideat 1117 JAS~~IINE ~^.V=::titUC~,
- I~e~t a.d Nomb~t)
For~T P1ercE , ST. LUG i E Connc~. ~'~oe~da.
~abt
and this statement is to be taken as n~ deeLration of eiti:enship. actual kgal residenoe and domic~e in the State d F'iorida.
IF FOR THE PURPOSE OF ENROLLING ~P FOR HOMESTEAO PURPOSES~
CNI_I~REN IN SCHOO~~ P~EASE STATE PLEASE CHECK: ~
THEIR NAMES:
CI Il1RL: ~ CI.AYTOi~t PO'. !~LL I I
~919 J!'~ -3 f~; ~ 30
• F:LED p.hG F~C(;h;rEO
ST.LUCIE COUNTY.ftA.
ROG~R POITRas
CLERK CIRCUIT COURT
FECGRD ~'£RI~tfC___~ •
. 450031
i I FURTI~i C,ERTIF7~ that I wn11 ngister at m~ bcal sddnss wben t1~e registration booics reopen. and oompl~ writh all
~ other raqniremeab ot s kgal reside~ of this State.
~ I FIJ81~iER CERTIFY tbat I hsve no intentioa to ntnrn to m former domiei'k. and I intend to remsin in
i . T. U C I E _ Count~.
~ t(~it~l .
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~ Fbrida. Permanead; -
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~ ._,,,~~....,...`;..t`~ .~s. ChaZles CZ~~,
~ ton Po::~ll
pvam.l
~ 1117 Jasmine Avenue
E " ~ leN1o+~~
~ Sworn to aad snb~rn~ before me this da~ of Fo r t i e r c e~ F 10- i I a S O
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` ~ . A.D.19_ ~9
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g ROGER P01 TRAS. CLERK OF C fRCUI T GOl~2T !
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ST. ~uc I E counm, FLoR ~ on ~
BY: ,
EPUTY LERK ~ •
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p 3L~0!! ~11 ?AL[ ~~IJ~ . ~ .