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Declaration of_ Domicile and Citizenship y
4'71391
TO THE CLERK OF THE CIRCUIT COURT.
ST. LUG I E COUNTY. FLORIDA: -
This is ~ declaration of Domicils and Cltisenship is tM State of Florida that I am SBag this dsy in sooordanee, and in .
conformity with Section 222.17. Flaida Statutes. I
I was f
~ a legal resident of ~ u 3 ~ 1 ~ _ ~ < < t h ~ ~ S and I
1(:n~l letaW
resided st ~ 0 3 ~ I~ a r k ~t~. S~' l^ ~ e-~" - However. I haw changed my domia7e to
(BtrMt and Namtwr)
a y t- da, of
and am and have been a bona fide resident of the Stets of Fbrida since f l
e e Q m ~ e- R ,19. . and i reaids at ~ ~ ~ ~ C~o T l~ . .3 b ~ S'~ e ~T
(BtrNt and N®bKl
~o ~ ~ ; ~ r _ ST . L UG I E County, Florida,
Ic~ul
and this statement is to be taken as my declaration of citi:eaship. actual legal residenos and domia7e in the Stets of Fbcida. 3
1
IF FOR THE PURPOSE OF ENROLLING IF FOR HOMESTEAD PURPOSES
CHILDREN IN SCHOOL, PLEASE STATE PLEASE CHECK:
THEIR NANES:
jam) a L ~ ~u
,;,--~e ~ ~ y 1980 JAN -3 Alt i~ 4
C TY FlA
f
R06E~ POITR SD "
CLERK CIRCIgT COURT
itECOIeO vERtFiEn._.._../~__
4'71391
I' I 1•'LJR1'IiER CERTff'Y that I wi71 register at my local address when the registration books reopen. and comply with all a
other requirements of a legal resident of this State.
l
I FURTHER CERTIFY that I have no intention to _ return to my former domia7e. and I mend to remain in
te r. t. u ~ .County.
i
Florida. permanenti;. .
•''•Ui~1~ C~•~.
' S
'eI';
, ? , (Name
- ~ ~ d
(Addrwl ~
Sworn to and subscribed beton me this day of -
i
A.D.18~_
t
a
ROGER P01 TRAS CLERK OF C IRGUI ~ COC~2T
ST. LUGIE COUNTY, FLORtOA
BY: e~ :J+-'~
EPUTY LERK
6001 PAGE
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