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TO THE CLERK OF THE CIRCUIT COURT.
5~.. LUG 1 E CUjj~.Y~ Fl?o~A:
~ 4'his is my declaration of Domicile and Citirensbip in the State of Florida that I am fling this day in anoordanex. ind in
conformity .vitb Section 222.17. Florida S lutes.
' I was formerl7 a legal resident of and I
(SLaf~
resided at Aowever. I have changed tn? dotnicHe to
(Street and Nma ~ -
and~(a.m and have bee(n~ a bona Sde resident of the State of Florida sine C l day od
0_1511 ~~X-~~ -19~, and I reside at a S , ~ , J h i .
~d~~ S ~ ~ ST. LUG 1 E~~a Nam
t'~ c
(~ouaty. Florida.
IQty) '
and this statement is to be taken as my declaration of atizeaship, actual legal reeideace and domia'le in the State of Florida.
IF FOR THE PURPOSE Ot% ENROLLING IF FOR HOMESTEAD PURPOSES,'
CHILDREN IN SGIfOOL, PLEASE STATE PLEASE CHECK:
THEIR NI?MES:
1Yl e ~ f 1. ~ -
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ST.ltiCt~ CU::HtY.Fi:~
ROGER POlTi'.i.
tlERit C.'aClt' : C 1" .
449'78
I FURTHl~t CERTIFY that I will register at my local address when the registration books reopen, and comply with all
other regainementt of a legal resident of this State.
I FURTHER CERTIFY that L have no intention to return to my former domica~e. and I inland tto remain in
T. U C I E ~ County,
- fCit~) .
Florida, permaneati;_
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J (Addreu)
Sworn to and subscribed before me this day of CS lJ~ S-~ ,
• L:~rND~ ~~/7A~K
ROGER POITRAS. CLERK OF CIRCUIT COURT S'~i %/Lr ~ ~
ST. LUG l E COUNTY, FLOR 1 DA _ -
BY: , ~ t
G - ~ ~ ~ ~
- EPUTY LERK
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