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TO THE CLERK OFTHE CIRCUI'yCOURT. -
- ST. LUG 1 E COUNTY. FLORIDA: .
This is my declaration et Domic~ and Citizenship in the State of Florida that I am firing this day in accordance. and in
R _conforauty with Section ?22.17. Florida Statutes.
I was formerly a legal resident of ~ and I
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resided at . However. I have changed my domicile to
Fred a_~] No~sD~l -
and am and have been a bona Sdc resident d the State of Florida sines _ day of
. 291_.,l~, and I reside at
. (Sired and Nwa~t~
~ ~j~. = e~ S T_ L UG I E County. Florida,
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and this statement is to be taken as my deelsr:tion at citiaenship. act:~al legaLresidence and domic~e in the State of Florida.
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- -IF FOR THE PURPOSE OP ENROtLIN6 IF FOR HOMESTEAD PURPOSES,
CHIIOREN IN SCHOOL, PEEASE~STATE PLEASE CHECKS
THEIR NAMESS -
t
- _ - i9~ JAN 24 AM ~ 2G
M.ED ANC REG9RDED
~LiUC1ECOlM Y.fIA.
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Ras
- ltECBRD VERtFCEit
I FURTHER CERTIFY that I w~71 register st my local address when the registration books reopen. and comply with all
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
T. U C I E ,County. 4
((ZRy) _ f
Fbrida. permanenti~
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'!/i.~~ ~ - ~.4~~~ - - !Name)
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Sworn to and subsrn'bed before nze this day of - t
.~.~[inu ; A.D.19 l3~
ROGER PO i TRAS, GLERK OE .G i RGU { T CO~R T
ST. LUGlE COUNTY, fLOR10A -
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- EPtlTY L.ERK - _ - i
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