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TO THE CLERK OF THE CiRCU1T COURT.
S'f~. LUG 1 E COUNTY, FLORIDA:
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~ This it m~ declaration of Domic$e and Citizenship in the Stt4 of Florida that I am fling this dad in accordance. and in
conformity with Section 222.1T. Floridt Statutes.
' I wts loaner a kgal resident of 5~Q ~ A LJ - and I
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resided u Sao ~ f it'_o N T 5 7 - Aowever. I have changed m~ domicile to
(Strcd and Numbs) - 1
and am and htve been a boat Sde resident of the State of Florida since y ~L / 7 g dq os
19 7
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- and I reside at X30 ~ S ~ ~ ~
13treut and N~bat)
~ • r cp _ ST . L UG I E Countp. Florida.
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and this statement is to be taken a, m~ declaration of dtizenship, 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:
THEIR NAMES:
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f IIEC ANC pj :alr.:!: u
ST.LUC~E C~'ttsTY.rLA.
ROGcR PQITftAS
- _ CLERK C!RC'~tT ~Cl!"j -
4S61~68
'I I F[TRTHER C7;RTIFY that I wSl register at m~ Iocal address when the registration books reopen, and ooraplT with aD
f other sequirement~ opt a legal resident of this State.
I F'iJRTHER CERTIFY that I have ao intention to return to m. former domicile. and I intend to remain in
J T~ L U I E _ Wunt~,
ICit~) _
Florida. pcrmaneati~.
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Sworn to anl~ab3arr~bed before me this ~ dad of - ,P
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ROGER POITRAS. CLERK OF CIRCUIT COURT ,
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ST. lUG1E COUNTY, FLORIDA _ - .
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BY: ,
• _ _ EPUTY LERK ~ .
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