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Declaration of Domicile and Citizenshi . ~ •
P
4'~21~8
TO THE CLERK OF TILE CIRCUIT COURT.
S T . LUG 1 E COUNTY. FLORIDA;
This is my declaration of Domicile and C[tisenship in the State of Florida that I am filing this day in aeoordaaae. and in
conformity with Section ?22.17. Florida Statutes.
~ ~
I was tormeriy a legal resident of ~ .t ' ri s t 1~! ' i~-~ `"7 G• ~ . ~ I.
resided at _.__~~C ~ ~ ~ i2 ! % +.S ~ . However. I bare changed my domicile to
l3treet sad Number) -
and am and have been a bona fide resident of the State of Florida since ~ ~ l day of
r.
1- '
-19 and I reside at
t3t:eet sad Numbar)
e ti t.t_. ST. LUG I E County. Florida,
and this statement is to be taken as m~ declaration of citizenship. actual legal residence and domicile in the S4te of Florida.
i
LEI I F FOR THE PURPOSE OF ENROLLING i F P'OR HOMESTEi?v ri3ilPii5E5,
CHILDREN IN SCHOOt.r PLEASE STATE PLEASE. CHECK:
THEIR NAMES: `f~-
~-:S~)~'r~ - ~~n rl~ ~ X71-4
3
- - fir; ~ il1u~- h~ w L~.~~ .-,r- . s
t ~ t - c~l:alt cll?cu)t COuA
-TT- N ~ A ~ ~~1U'C CCLk U ~ (t;-Gl1PtI YE?if iF"•
' ~L\(,\ 1 0. i~~f' C~` LJCOCI~- ~ 4 I F.r~~G~7
I FURTHER CERTIFY that I wt11 register at my local address when the registration books reopen, and comply with a!1
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
~ ~ r :
. ~,.r-t-a~--_ - U C 1 E .County.
(City) .
Florida. permanenti; .
. '1(i ~ ~ rr .awl A', ~ f. ~ ~
~~il''~~G;,•*,~ t^~S~
~c~~ (Name) .
_ J (Address) -1/ ~ _
Sworn to and subscn'bed before me this ~ day of ~ . C ~ t }l •
~ i h ~
~ f,~an_ .A.D.19,$t.! ~rL~l1F^T CSt7L<i~
.ROGER POI TRAS. CLERK OF G IRGUI T COrJ~2T
ST. LUGIE COUNTY, F1_OR1DA
c~
EPUTY LERK ''''rte '
6ti0~K ~NGJ PtGE •