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45~5'?'99 -
'fd 1 riE CLERK OF THE CIRCUIT COURT.
S~'. L UC I E covrrrsr, FLORIDA:
4"his Is my declaration of Domicile and CitiLensbip in the State of Florida that I~ am Sling this day in accordinct, and is -
_ conformity witb Scetioa 222.17, Florida Statutes.
` I ~ as formerly a legal resident of ~ ~ C~ ~ ~ ~ ~ ~ ~ O and I
p (CSty) (Stale)
resided at ~e y ~r /7' / J 1•
However, I bave ebangrd my domiu7e to
(Street and Numbes) ` -
a nd rsn and have been a boas Sde resident of the Stan of Florida since ~.Ju-~ Y l l 9 ~ r day of
_ _ _ ~ 19
~
9 and I seside at ~ ~
~ ~~~5 ~ I'4 h~ iL~'-' -
p (st~t ana Nu~~) -
(G~t~) Cosnty, Florida.
and this stattment is to be taken rs my dedaratioa of otizenship, actual legal residence and domin7e in the State of Florida.
IF FOR THE PURPOSE OF ENROLt.IHG IF FOR HOHESTEAD PURPOSESi
CHIL.DRE#1 IN SCHOOLS PLEASE S7ATE PLEASE CHECK: ~ .
THE)R NAHES:
-
'9i9 1~'J
_ ~ ~ ~
_ - - i~AR9 vE`RI~Eti~.~ _
~ I liii'li:i3 C~ TIr'Y thst I ~:-?71 register Ft ray Io:sl address when the registration books reopen, and comply iLh zl)
:r'.`,:er requi.-etnents of a legs) resident of this State. -
f
~ I i URTI3"R CERTII•'Y thtt I have no_ intkntion to return to my former domiu'Ie, and I intend to remain in
f
- _ T. U C 1 E County,
ICr~) _
I1:zn+e} ~ -
1 • ~ - ,C.c.s-~-* k ,`.l
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F (Address)
~ • ~ r.3 s ct• cry.. d teforc ~r:e this _ day of
€ -
~.n.19_ `
e
_ `~`~:2 i'O1~-:Z~~S_,~___Cl_Fr~K OF G tRCUI T GOt.,f-2T , ,
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~,-r. Ll1C 1 E cot3r•~TY, Ft0:2 ~ oA ~ . • °
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y, ~ yam. ~ ; . -
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