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Declaration of Domicile and Citizenshi `f
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4Ei428'7
TO THE CLERK OF THE CIRCUIT COURT,
ST. LUC 1 E COUNTY. FLORIDA: .
This is ray declaration of Domicile and Citisenship in the State of Florida that I am Sling this day to aooordanae. and in
contarnut~r with Ssctioo 222.17. Florida Statutes.
J was former a legal residers of ~ and I
~71 (&aN)
resided at However. I love changed my domicile to
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and and have been a bona fide resident of the State aI Fbrida since - day of
19 / and I at
1 and ambK)
S T. L UG I E County. ~7orida.
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and this siatemeat is Lo be taken sa my declaration of ritiseasbip. actual legal residence and domicile in the State of Florida.
IF FOR THE PURPOSE OF ENROLLING IF FOR HOMESTEAD PURPOSES,
CHILDREN IN SCHOOL, PLEASE STATE PLEASE CHECK:
T E 1 R NANE ~ ~
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3 ~v 30 S°' t
?~i1FU LKC ~2itAdhU
SLIUaE CQJNTY.ftA.
ROGER POITRAS
CLERK CIRCUIT
I FURTHER CERTIFY that I wdl register at my local address when tbe registration books reopen. and comply with all
other requ~iremeats of a legal resident of this State.
I FUR1'fIER CERTIFY that I have no intention to return tom former domicile. and I intend to remain in
U G I E ~ County.
ICityl
Florida, permanensi; .
`~r;y `'QU1~T`
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Sworn to and snbeeribed before me this day of / .
. A.D.18
:
ROGER P01 TRAS. CLERK OF G IRGUI T COURT
ST. LUG I E COUNTY, fLOR 10A
. EPUTY LERK .
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