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Declaration of Domicile and Citizenship
4'712ti:3
TO THE CLERK OF THE CIRCUIT COURT.
ST. LUG 1 E _COUNTY, FLORIDA:
This is my declaration of Domicile and Citizenship in the State of Florida that t am filing this day in nooordanoa. and in
conformity with Section 222.17. Florida Statutes.
I was formerli a Legal resident of ~~~t~ ' sad I
2 1Cit)) (Stab)
resided at 3a7 ~ L,~~i //ntt) 1.//L However. I have changed my domicile to
tract sad Number) '
and am and have been n bona fide resident of the State of Florida since ~ ~s~ day of
J / !Q rC/'1 .19~ and I reside at l5D ~ ~1~I^O ?"!O~
i3treec and Number!
~O r~ ~
i 2 rC~ _ ~ ST . LUG ! E County. Florian.
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and this statement is to be taken as my declaration of citizenship. actual legn! residence sad domicile in the State of Florida.
I F FOR 7HE PURPOSE OF ENROI.t. LNG I F FOR HOI:iESTEAt! PURPOSESs
CHIL.OREN IN SCHOOL, PLEASE STATE PLEASE CHECK:
THEIR NAMES:
19T9 UEC 3 t PE; ~ 4 0
` = ffLFO AN FEC (cU D
-r"~ SEwOGE ~POI~~ftAyA.
41ERK CIRWiT COURT
~ERIFtfO
4~~3
I FURTHER CERTIFY that I wi71 register at my local address when the registration books reopen, and comply with all
other requirements of a legal resident of this State.
I FURTHER CERTIFY that I have no intention to return to my former domicile. and I intend to remain in
, 7. U C I E ,County.
ICit~) _
Florida, permanen~i; .
~~OUNl
C' r'
Cam:
~ •'OG / ~
~ ~
. s ~ /
tE.M.~ O
c,FCO~~.E` (Name)
IAddeea~)
Sworn to and subscn'bed before me this ~ ` day of
~D _ l
ROGER PO I TRAS, CLERK OF CIRCUIT COURT
ST. LUCIE COUNTY, FLORIDA
BY:
EPUTY L.ERK ~~cc~~cc~~
8001 ~iG•~ P1Cf 2S~