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Declaration of Domicile and Citizenship
4'75484
TO THE CLERK OF THE CIRCUIT COURT.
ST. lUG i E CpUN'pY~ glpg~A;
This is ~ declaration oI Domicile and Citi>Denship in the State of 1:7orida that I am IDing this dad in aecordanoe. and in
oonfotatitT with Seetian 228.17. Florida BLtWes. j
. . I was former a legal resident of /V ~ ~fi' ~ /C ~ and I
/ p~ lCt1,~) 1
resided at `D 4 .~Le1 ~ , / ~ J 7 -However. I have ehaaged m,Y domi~7e to
tt3a..~,..d Nae.e.r)
and am and have been a bona fide resident of the S4te of Florida since !1 ~ ~ daT of
~fI N e//}.~ y ' .19~..~ aad I reside at fir? il- ~ /t+~~P.~o C~iu~
~ (8t~t sad N~bwi
J~61~~..~E~t,GP~ ~ ST. LUG I E Count, Florida.
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and this statement is to be taken as ~ declaration of dtisenship. actual legal reaidenee and domicile is the State of Florida.
IF FOR THE PURPOSE OF ENROLLING IF FOR HONESTEI?O PURPOSES,
CH 1 LOREN 1 N SCHOOL., PLEASE STATE PLEASE CHECK:
THE~1 R NAMES: ~-J
_ ~ ~ X80 fEQ -1 PM ~ 06
_ FILE~AlM FECORDEO
ST.L IE CCUNTY.FIA.
ROGER POITRAS
CLERK CIRCUIT COURt
REs:itlt® VERIFtEO
4~7a)4~4
I FUR1'IiER CERTIFY that I w~ register at m,T Loin address when the registration boots reopen. and oomplT with all
' other raluirements of a k;al resident of this State.
I FURTHER that I have no intention to return to mT fa~rmer_ domidk. and I intend to remain in
_ _ U 1 E ~ Cou~T.
_ ICItYI
f Florida. permanend; . ~
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snbscr,3ed before me this at ~7 ~l ~-~~y1Lt~~ 3 yd` Z~
~i
A.D.183r..~.~
ROGER P01 TRAS, CLERK OF C IRCUI T C0~2T
ST. LUG 1 E COUNTY, f LOR 10A
BY: • . .
4 EPUT+
Y ZL.ER '
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