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Declaration of Domicile and Citizenship
4`71404
TO THE CLERK OF THE CIRCUIT COURT.
ST. LUC 1 E Cpj~Y• ~,O~A; .
This is mp declaration of Dotaleile and Citiaenahip is the State of Florida that I am filing thL day is aeoordanos. sad in
confazmity with Section 22g.1T. Florida Statutes. J
I was former a bgal resident opt ~ ~.,y i s b u--~cy ~ / P h a. sad I
Ba'~~G..L ,P~ ~o ~~b) (State)
resided at 73 S ~/~-/L ~ 8owever. I have ehaag~sd rep domicile to
(Street sad Naeberl
sad am and have been a bona fide resident of the State of Florida since 1~a~' day of
19.... and I reside at 1~1Q.2 ~ /~d•~ ~ h ~ S.~/` ~s/~,~
Po r7 ~ ~ ST. LUG I E~e`a~ 1
Connty, Florida.
iC14)
and this statement is to be takes as aqT decLratioo of siti;enship, actual legal residence and domicde in the Sots ~ Florida.
IF FOR THE PURPOSE OF ENROLLING 1`F FOR HOMESTEAD PURPOSES,
CHII.OREN IN SCHOOL, PLEASE STATE PLEASE CHECKt
T-H-E I-R- NAMES! - -
r-
~e0 JAN -3 ~ ~i: ~s
- F~~~~ED~~AEEtt~~t? RECOROtO
sT~tOtiER ~ Ri1~A.
CLERK CIRf~1~COYRT
RECOItO VERIFtEp_,
- 4'71404
I FUR'1~ CERTIFY that I w~11 register at my local address when the registration books reopen, sad comply with all
other requirements of a legal resident of this State.
I FURTHER CERTII~'Y tbat I have no intention to return tom former domicile. and I intend to remain in
U C ~ E ~ County,
usc,~
Florida. pcrmaaeasi; .
y,'•z ~ ~ (Name)
y~: ~ G..? s.~
~ r~.~~,~ ,ter
_ c~FCCUraY.F~ ~ _ ~1, •
Swore to and su before me this 3 day of o< s .~Ctr~i.Q
`-~R N y 12~ A.D.19.~._• 1~Ru N ~ ~9 i -
ROGER PO I TRAS, CLERK OF C i RCU 1 T COCdRT 3~~u~t= ~
g%~ ~
ST. LUGIE COUNTY, fl.OR10A
EPUTY t.ERK
g~323 P~ 504
ara c.,...