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4'7589
TO THE CLERK OF THE CIRCUIT COl'RT,
ST. LUG 1 E cov~TY, FLORmA:
This is my declaration of Domicile and Citizenship in the State of Florida that I am tiling this day in accordance. and in
conformity with Section 222.17. Florida Statutes. ~ ~J
I was formerly a legal resident of , / V . and I
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resided at ~ ~i ~ ' . However. I have changed my domicile to
IStrest and Number)
and am and hav`e/been a bona fide resident of the State of Florida since ~ day of
3~
.191L~. and I reside at L uJ ~D~
f ~ • i 18tewt and Number)
~ P r r~ ST . L UG I E County. FMrida,
ICi?y)
and this statement is to be taken as my-declaration of citizenship. actual legal residence and domicile in the State of Florida.
IF FOR THE PURPOSE OF ENROLLING IF FOR HOMESTEAp PURPOSES, ~
CHILDREN IN SCHOOL, PLEASE ST-ATE PLEASE CHECKS
THEIR NAMESS
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3T.~L'C=E CLt'VIY.fI:~.
RQGER POiTRA~
CLERK C!p,.~~:; ~•y~~~-
4~i'7589 `
i
I FURTHER CERTIFY that I will register at my local address when the registration books reopen, and comply with :U
other requirements of a legs! resident"of this State.
R s
I FURTHER CERTIFY that I have no intention to return to my former domicile. and I intend to remain in '
T. U C I E County
ICit~? i
Florida. permanence; .
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r (Addreae)
Sworn to and subscn"bed before me this ~ day of 7 Q ~/C` ~
~G Ll-P/jst/LC~~ A.D.19_
79 t
ROGER P01 TRAS, CLERK OF CIRCUIT COURT
ST. LUG I E COUNTY, FLOR t A
BYS
EPUTY LERK ~m
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