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Declaration of Domicile and Citizenship ~
4'72664
ToR~ cL>;R~ oFTI~e c~currcovRT, •
ST. LUC 1 E CpU~Y~ ~,p~A;
This is my declaration ~ Domie~le and CIti:enship In the Stets opt Florida that I aan filing this day is aaoordanos. and in
conformity with $ectioa 222.19. Florida Statutes..
I was forme a kgal resident of ~ ! a-- and I- .
(Statal
resided a! ~ ~ LLB. ~ - _ However. I have changed my domieae to
(Str«t and Number _ -
and am and have been a boas fide residcen"t' of the State of Fbrida since / day of
' 19_,,~
v. and I e~e.+ide at ~ ~ tal3~•L.-x~ a.~ ~~-~J ~•eh~~v,,~
f,,~-r,~ _ ~ ST. LUC I E qty, Florida. -
«xtl
and this statement is to be taken as my declaration of citizenship. actual legal residence and domide is the State of Florida.
- IF FOR THE PURPOSE OF ENROLLING IF FOR NOMESTEAO PURPOSES
CHILDREN IN SCNOOLr PLEASE STATE PLEASE CHECKS
TNEtR NAMES:
1980 JAN ! 5 PM ~ 4 7
- - ~3 F1LEO AND RECORDED
ST IUCIE COUNTY. Ft A.
ROGER POITRAS
- ~ CLERK CIRCUR COUR
- - RfC~RD VERIFIEb
- - 4'72664
I FLTRTI~R CERTIFY that I wi11 register at my local address when the registration books reopen, and comply with all
other regteirements of a kgal resident of this State.
I FURRIER CEI~TII~'Y that I have no intention to return to my former domicile. and I intend to remain in
r _ ~ ~ J ~ . U C 1 E County,
((Styl
Florida. permanencl; .
• ~ _
- r.
''nrr'~ G•
(Namd
(Addrw)
Sworn to and subscn`bed before me this day of '
A.D.19 8 0.~ .
ROGER P01 TRAS, CLERK OF C IRCUI T COC~2T
ST. LUCIE COUNTY, FL~29DA -
EPUTY LERK ~j _ s