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7`0 THE CLERK OF THE CIRCUIT COURT.
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S~'. LUC I E CO~~Y~ ~,p~A;
~ 4'his is my declaration of Domicile and Citizenship in the S4te of Florida that I am fling this day in accordance. and in
confortaity with Section 222.17, Florida Statutes.
J- ' I was formerl a legal resident of 0 w ~O r 1C _ and I
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resided at ~ ~a X ~ _ _ However, I have changed my domic~e to
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and am and have been a bona Sde resident of the State of Florida since 1~/U U ~ ~ dal ad
- N n U . _ 19 7
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- and I reside at 76 O ~ S~'~'` ~a i ~o S ~ n /~4~~c~1 ~
(9veeR and Numbes) +
• ~ f • ~i• a rc' a ST . L UG I E County, Florida, .
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and this statement is to be taken as my declaration of citizenship, actual ]egal residence and domicile in the State of Florida.
IF FOR THE PURPOSE OF ENROLLING IF FOR HOHESTEAO PURPOSES, ~
CHIIOREN IN SCHOOLa-PLEASE STATE PLEASE CHECK:
THEIR NAMES: ~
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FIL~c ervC t~ ~c~+~~:,
SLLUCI;: GOI:NTY.Ft:..
ROGER POITRAS
CLERK CI3CUIT COL+c2T
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I FURTHER CERTIFY that I will register at my )ocal address when the registration books reopen, and comp]y with all
E other requirements of a legal resident of this State.
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I FURTHER CERTIFY that I have no intention to return to m. former domicHe. and I intend to remain in -
. T~ U C I E ~ County, 1
's _ (City) , - ~
~ Florda, permanencl;.
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(Addreas)
1 S..orn to and ore me this day of
- _
Ne r e.M e r ~ . /~D.19_
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ROGER POITRAS. CLERK OF CIRCUIT COl~2T . _
ST. lilt i E COUNTY, FLOR 1 OA
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BY: ~
- EPUTY LERK ~R~~ PAGE i~
BDOK
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