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D~ciara~ion of Dornicil~ and Ci~i~~nsi~i~
4`r'J53~.
TO THE CLERK OF THE CIRCUIT COURT.
ST. LUC 1 E apU~y. ~,pglpA;
This is mT declaration of Domicne and Citisenship in the State of Florida that I am Sling this da,F in aeoordanoe. sad fn
oontormit~ with Section 222.17. Florida Statutes.
I was forme a legal resident at ~ ~d ~ - l
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resided at 10 ~ d~ ~o/ Y ~y~- ~ _ Howevar. I have el~aaged rn~ domie~e to
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and amend have been a bon: ilae r~esideat of the State at Florida sinotf l~~l dp of
_ /~C~~c .1l~.. and I wide at ~?oy ~/~°~!d
ISirwt ud Nasb~
~ ST. LUG 1 E
cGal
sad this statement is to be taken as aoT decLration of dti~enship, actual Iegal residence and domia'le in the State of Flacida.
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, IF FOR THE PURPOSE OF ENROttING IF FOR HOMESTEAD PU-RPOSES,
CHItOREN IN SCHOOL, PLEASE STATE PLEASE CHECK:
THEIR NANES;
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190 ff6 28 F~ 1~ Q!
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SE LIfC1E CWtIT Y. ~t A.
RDGER POlTRAS
I;LEfiK CIRCUIT CL`URT
IFURTHER CERTII''Y that I wID resister at aq local address when the registration boob reopen. and oomph with aD
other regniremeMs of a legal raddent d this State.
I FURTHER CERTff'Y that I have no intention to return to mT former domicile. a~ I Intead to remain is
--ST_ LUCIE
. Coaaty.
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Florida, permane~;.
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Swoe~n to and sobeaibed before me a g
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R~ER POITRAS, CLERK OF CIRCUIT COtdRT
ST. LUCIE COUNTY, t~LOR I W1
BY;
EPUTY LERK
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