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D~ctara~ic~ri of Dor~icil~ aid Cifii~~~t5iii.~
TO THE CLERK OF THE CIRCUIT COURT. Q
ST. LUG 1 E OOUI~TY. FLORIDA:
Tbia is mT declaration of Domicile and Citisenship in the State of Florida flat I am Sling this ds, in aoeordanoe. and is
oonformit~ with Section 222.17. Florida Statutes.
I was formed a legal resident of ~ T ~ ~
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resided at ~ ~ ~ A ~ u ~ ~ ~ ~I J4 ~ ! ~i-C HoWeyer. I have changed ~ domin7e to
(8tred NomDar)
and am and have been a bona fide resident of the State of Florida since S U~ ~l TEN / ~ - ~ ~
r-~ Q l ~T `
~ _ 19_-? - and I reside at ~ ~ ~ V ~ ~ l ~ T
_ 1Strart and Nambae)
-r U ~ C _ ST . LUG ! E Countg. Florida.
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and this statement is to be taken as ~ declaration of citizenship. adnal legal residence and domidle in the State of Florida.
IF FOR THE PURPOSE OF ENROLLING ~ !F FOR NOMESTEAO PURPOSES,
CNlLOREN IN SCHOOL, PLEASE STATE PLEASE CHECKS
THEIR NAMESS
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'CLERK CIRCUtT CCU~T ~1.~
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I FURTHER CERTIFY that I wiII register at m~ local address when the registration books reopen. and ~mPb with aD
other requirements of a legal resident a[ this State.
I FURTHER CERT'I1:R that I have no intcation to return to my former domic~7e, and I intend to remain in .
S T. L U G ~ E . Connt~.
_ _
Fbrida. permanenrI,•.
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Sworn to :ad snbscn'bed before me this ~ di,F at_ ~ ~ ~ ~ _
Q
ROGER P01 TRAS. GLERK OF G 1 RGU 1 T COtdI2T
ST. COUNTY, fLORtDA ~ .
BY: c C
EPUTY LERK -
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