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Declaration of Domicile • and Citizenship
4'71469
TO THE CLERK OF THE CIRCUIT COURT. .
_ ST. LUG i E CpU~y, FLORIDA:
Thi, is my declaration of Domia'ls and Citiaeaship in the State of Florida that I am ~6 tlua day ~ acaoraanee. and is
conformity with Section 222.17. Florida Statutes.
I was tormarl= a legal resident of ~ ~ o ~e /Vo r t1+ . ~I?I eO~~ nay- and I
(t:k~) IStatd
resided at _ 3 /~G 1~iP>'/e~ ~f
re4 at l~~ gowever. I have changed my domic~s to
(8tr.~t asd Namb~rl J
and am and have been a bona fide resident of the State a[ Florida since II / day of
,De c e:..c~i a R, .19_~. and I reside at ~ ~f~ e r r y •/I j~ol. !'V.'rr~.rc ~ /l ; n f"
I8ttwt sad NomMrl
f
orf ~f• l~.u c i e ST. LUG I E County,F7orida.
ICttyl
and this statement is Lo be tskaa ss ~y detlaratioa of citizenship. actual legal residence and domicile in the State of Florida.
.IF iOR 7HE PURPOSE Of ENROLLING IF iOR HOMESTEAD PURPOSESa
CHILDREN IN SCHOOIr PLEASE STATE PLEASE CHECK:
THEIR NAMESt /
~'~u~ ~~wArcf ~ANi c ~s ~~Q,
Jose f-'~ - -I o~%~ ~RN; e I S 1980 JAN - .
3 P!~ ~ OS
FICEO ANO RtCOR 0
ST~L~ER
PO
TR
~ A•
CLERK CIRCUIT CO
- - RECOR9 VERIFY
- 4'71469
I FURTIiER CERTIFY that I will register at my heal address when the registration books reopen. and comply with all
other requirements of a legal resident of this S4te.
I FURTHER CERTff'Y that I have no intention to return tom former domicile. and I intend to remain in
U C 1 E ~ County,
((qty)
Florida. permanencl; . -
.~~..~:~.,;f,
'fr
_r.. C
~ar~
I
Sworn to a bscn'bed before me this ~ day of _ ~ t~Z~_-- 13 f
3 Z
.
A.D.19•_.
RO I TRAS CLERK OF C iRCUI T C0~2T
ST. LUGIE COUNTY, FLORIDA -
EPUtY JERK
6COX ~~IGJ P>tiGE ViJ~+ •