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'FO THE CLERK OF THE CIRCUIT COURT. ~ f , 4
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S'~. !UG 1 E COUNTY, FZARIDA: ,
This is my declaration of Domicile and Citizenship in the State of Florida that I am Shag this day in aocordanoe. and is
_ conformity sQit6 Seciion 222.17. Florida Statutes.
I was formerly a legal resident of ~,A~'e~Q.~Ri,A ~ _ ~b`~'1~C'l . and I
l 'ty) (Stale)
resided at ~ ~ C~~~x~~~.2~~ - However I have changed my domic~7e to
(Street and Number) . -
ard am and have been a bona Gde resident of the State of Florida since ~3 day of
~~eih ~ 29 - !
ZS
- and I reside at ~ ~ ~ ~d . ~~fi~
(3u+eet nail Number .
• ~L.~ p~ `ek'c~ try) ST. - LUG I E County. Florida,
and this statement u to be taken as my declaration of citizenship. actual legal residence and domia~e in the State of Florida.
IF FOR THE PURPOSE OF ENROlCtNG IF FOR FlONESTEAD PURPOSES,
ClillOREN IN SCHOOL, PLEASE STATE PLEASE CHECK:
THEIR NAMES: !
_ ;
. 1~:iua~rv'3
1979 ~?tt~ 16 Pb ~ !0 .
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mutt L
RcCQf,'U YFtllflf~_ _
I FUR3'HER CERTIFY that I wt~ll register at my locsl address when the registration books reopen, and comply Kith s11
other requirements of a legal resident of this State.
I FURTIiER CERTIFY that I have no intention to return to mg former domic~7e. and I intend to remain io .
T. U C I E .County.
lCit~) _ _
:'Io:ida. per-.nznen~i~.
~ouNry _
. ~ ~ C~ iN f rna~T
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a~C1lM~~'~ -
Ixame
Sw~or» to and subscribed before me this ~ day of
- c . A.D. 19
~ ~1 .
i:OGER POI TRA Cl_ERK OF C ! RCU f T COURT ~ , •
ST. l COUNTY, FLOR t OA
BY: ~
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Bo~K 314 P~~E 2164 ~ _
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