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4~36~ ~ ~
1;0 THE CLERK OF THE CIRCUIT COURT.
ST. LUG 1 E Gpt~.y, FLORIDA:
This is m~ der]aration o! Domir~e and Citizensbip in the State of Florida that I am fling this day is aoeordanex. and in
cnnforrnity .vitb Sectio~a 222.17. Florida Statutes.
~
' I wu lormerly a legal resident of C ~ G D ~ ~ and I
1(xt~) . ISt+t.)
resided at ~9 ~D . ~~Yh n~ ~ ~ l~ ~ ~ ~Jr= However. I have cbangt:d m7 domict~e to
(Street and Number) T - -
and am and have been a bona 5de resident of the State of Florida since
~!_l ~ dal of
19'79 _ and I reside at __107 ~~1~/~ ~ S• 7~
(3tr+st and Nnmbar)
~~3 ~'7'~ ~~RC'c ~~oIP/ o~~} ST. LUG I E County. Florida,
tuts) -
and this statement is to be taken as my declaration of dtizenship. actual Iegal residence and domin7e in the State of Florida.
IF FOR THE PURPOSE OF ENRO!lING IF FOR HOMESTEAD PURPOSES,
CHILDREN I N SCHOOt., -PLEASE STATE PLEASE CHECK:
THEIR NAMESS
1..x/9 < O f ~ ~J9 .t°~Q ~ ~j -
0?9 h'JV 19 A1•a i l~ I S
f11L0 AI~'C F CGr•: t U .
SL UClE COU:ltY.F~:..
~£R POIIRA~
~P,~(CtRCUiT CGU~t /
46369
I FURTHER CERTIFY that I ~ register at my 1oca1 address when the registration books reopen, and comply with all
o!her requirements oia Iegal resident of this State.
I FURTHER CERTIFY th:t I have no intention to return to my former domict~e. and I intend to rrmain in '
- 7. U C I E County.
- lCitj) _
Florida, permanenti,:
r ~
•a~~,~':>l;J:- (Name)
(A~dtsaa)
Swots to and snbsrn'bed before me this ~ day of
~ A-D.19= 71
RQGER POITRAS. CLERK OF CIRCUIT GOl~2T ~
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1 • ~ ~
ST. LUG I E COUNTY, FLOR 1 DA - -
BY: ~ ! ~ .
EPUTY IERK .r
1) i
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