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~o Tx~ cLERIt of rxE cli;cvrlr covRr, 4~?~4'76
S'f. LUC 1 E covN'rY. FLORIDA: ,
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4'his is my declaration of Domic~e and Citiunsbip is the S4te of Florida that I sm fling this day in accocdiwoe, and~io
_ conformity with Section 222.17, Florida Statutes.
A ~ s~
I was formers a legal resident of /'//_~('~Y ~~O k v~A'~1 ~g ~ and I
` tat>> lstale)
resided at is ~T~ ~vl.r„{' 5~~~~f However, I have changed my domie~7e to
IStreet and NNumbet)
a nd am and have been s bona Sde resident o! the Stale of Florida since r y f~l day a!
19_.,2.1„ and I reside at ~311d r h ~rJ?~Yf
18tse.~ and Nacoberl
~ e~-c ~ ~ ST, l_UG f E County, Florida,
t(om)
and this statement is to be taken as my declaration of citi:eaship. actual Iegal residenu and domiale in the State o! Fbrida. ?
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IF FOR THE PURPOSE OF ENROLLING IF FOR HOMESTEAD PURPOSES
CHILDREN tN SCHOOL] PLEASE STATE PLEASE CHECK:
THEIR NAMES:
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- I9T9 lIUG 17 PM ~ O7
CLERK CIRCINT COURT ? _
RECORD VERI~IEO
I FURTHER CERTIFY that I will register at my local address when the registratian books 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 domicDe, and I intend to remain in
_ _ $
T .TU C t E ,County.
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F'i~~rida, pr_rmaneati~:
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(Name) -
~~o/~~~ ~~t-
(Addrest)
~rn to and subsmbed before me this _ 1 day of !L~ /~P~-~' f~
,
_'OGER POI TftA CLERK OF_ CIRCUIT COURT ~ "l:~"r:',,~ ,y
ST. l.t1G i E COJNTY ~ _ - r
F'LOR 10A -
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EPUTY ALE :~"=',yr .k":~". ~tl~.=
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