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Declaration of Domicile and Citizenship
4'71421 i
TO THE CLERK OF THE CIRCUIT COURT.
ST. LUG I E COUr1Ty, r-jp~A;
This is ~ declaration of DomicDe and Cltissnship in the State of Fbsida that I am ~S this da,~ in aceordanoe. and in
conformity with Section 222.17. Flaarida Statutes.
I was former a legal resided oIl ~ i e n+ o,tid ~ ~ r ' ?y~ ~ and I
A p ~ _
resided at / ~ 1 ~A'~'~` a y $owever. I havelcbanged nqy domic7e to
(Ste+Mt and NesD~N /
end sm and hava been a bona fide resident oohs State otFlorida since _ ~l P u p r ~ dq of
19~ and I reside at T z 9 ?'y1 U ~ ~"t `N ~
18teMt and Nrtab~e)
J~or7 Sj; ~+u c. e. ST. LUGIE ~ti,
Icxb~
and this statement is to bs taken as m7 dee4ntion ~ citizenship, actual
legal residence and do~7e in the State of Flocids.
IF FOR THE PURPOSE Of ENRO!lING IF FOR HOMESTEAD PURPOSES
CHIlOREN IN SCHOOt.r PLEASE STATE PLEASE CHECK:
THEIR NAMES:
_
1980 JAN -3 PN 1:46
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ENCgqRf~~TY~F A
R06EfI POITAAS
CLERK CIRCUIT -
RECMS VERIFIEQ
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4'71421
I FURTHER CERTIFY that I w~71 register at mT local address when the registration books reopen. and oomph with ail
other requirements of a legal resent of this State. _
I FURTHER CERTIFY tlmt I Nava no intention to return tom former domicile. and I intend to remain in
U C 1 E Count.
(C'it~)
Florida. permanenLl; .
~ IN )
Sworn, ~ ' ~ ~ubscn"bed before me this y~._ dad of
u'rw` A.D.1
- ~-se~~y M , S~OCI~1-e I /
R P01 TRAS. LERK Of C IRCUI f COCdF2T
ST. LUG I E COUNTY, Ft_OR 1 DA
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EPUTY LERK
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