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Declaration of Domicile and Citizenship
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ST. LU41 E (,OUN'!'Y. FLORIDA:
This b nq declaratiob at Domictie sod t~senship in the Stag ai Flosda that I asn lfying this dy is scoordanoe, aAd is
contormt4T with seetioo 224.17. Florida Statntaa. .
. - I was i a legal resident oI / ~ t~w.~ ~ [ ! S final ~ ~l4 NLI,FI---and I
ccw~ l
reaidea at Q~ ~ ~ ~ r )wc bt) S ' Aowever. I have ~nged rep domicile to
and sm and have been a boas Sds resident at the state d Florida since / S t~ rip of
~n r P W1 ~ c 12,' _ lsa~.. and I reside at , -S;11 ~SOt~i~ ~~dP.~~_~f'
t~r.rtdNsstb~d
r~ ST. i IJG I E ~.;~.~'.~s,.
cagl
and this statement is to be taken as aoP declaration ai dti~nsbip. a~twl ~ residence ~ domicile m the States d Flaida.
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If fOR THE PURPOSE Of ENRO<.LING ~If fOR HOMESTEAD PURPOSESi
CH 1 t.OREN !N SCNOOt., PLEASE STATE PLEASE CHECKt
THEIR NAMES:
• ~ ~'~rrtrnu ~'e~n ~J~vf
_ ~ - ice! ~E8 ~ ii=
F EO ~ ppRE~~CW~DED
$cP01T1YlAS
q,f Rlt CIRCtflT L'WR?
RECQRD YERIf tE0
4'75i~;8~2
I F1JR1~R CERTIFY that I wSl register at m7 heal address when the registration books reopen, and eomPb with all
other regna~ements of s bgal resident of this Stile.
'i I gORTHER GF,R1'jF'Y that I have ~ intention to return to former domia7e. and I intend to remain in
JT . t E
(0141 .
Florida. permanend,; • .fs
i•
~ colsNry ? ~ ~ Gc
cC~2. .fi
:v ~O Sam
~r. ~
swam to and are me this d+?7 ~ .
- rNAy T~
ROGER POiTRAS. CLERK OF GiRCUIT C0~2T
ST. LUG I E COUNTY, f LOR t OA - , ~ . _
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BYs
EPUTY t.ERK g~~'~
4 ~
• AGO Form 71.22