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T`0 THE CLERK OF THE CIRCUIT COURT.
ST. LUC 1 E COUNTY. FIARIDA:
This islny declaration of Domicile and Citizenship in the State of Florida that I am fling this day in accordance. and in
canformitj with Section 222.17. Florida Statutes.
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I was former a legal resident of + ~ -ti~~"' ~ ~ ~ ~ and I
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resided at - However. I have changed my domicz7e to tt
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and am and }cave been a bona Ede nsideet oitbe State of Florida since „;;~„e ~ day of
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.19~2~,. and I reside at }
(Street amber) }
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c.Q ~ ST . L UG I E County. Ffor;ds,
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and this statement is to be taken as my declaration of citizenship. actual legal residence and domiu7e in the State of Florida. ~
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IF i'OR THE PURPOSE OF ENROLLING If FOR HOMESTEAD PURPOSES,
CHILDREN IN SCHOOL, PLEASE STATE PLEASE CHECK:
THEIR NAMES:
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t979 OCT -9 P;! 2~ t !
fILEU A4C ~ECJnDCC
SF.L~CIE COL':IjY.ftA.
ROCaER NO)jRASt
CLERK CIRCUIT tOJR~. t
46193'7
I FURTHER CERTIFY that I w~71 register at my local addrexs when the registration 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 domiu7e. and I intend to remain in
_ T. U C I E .County. -
ICit7) .
,
Florida. permanenti;.
9-07 -~~C~c-L-~~
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Sworn to and st,bsc„bea before me this / day of `J 61 6~ ~`'f~-
- ~ C-~ 6 ~ - A.D. l9
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RQGER POI TRAS, CLERK OF C I RGU I T COURT ~ -
ST. LUC1E COUNTY, fLOR1DA _
BY : v / l.~~ati~~ x
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EPUTY LERK ~j<
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