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Declaration of Domicile and Citizenship
. 4'781.9
TO THE CLERK OF THE CIRCUIT COURT..
ST. LUG 1 E ppU~y. ~,pg~A;
i
This is declaration of Domicile snd Citisenship i4 the state of Florida that I am filing this d~ in accordance. and in
confannit, with Sedioo 222.17, Florida satutes.
I was formed a legal resident of ~q:l~'t~/i9 ~1
~ t~i4 and I
resided at _ However, I have changed ~ domic~7e to
tstre«.oa tvme.r~
and am and leave been a bona fide resident of the State oiFlorida siaoe ~ day at
,4~`z 19~.:nd I reside at ~O/'~ ~/~J/~C. ~
~T ST. LUG I Est~.ts,aNo~e.~!
Count. Florida.
tcw)
and this statement is to be taken as mT declaration of eitiunship; actual legal residence and domicle in the State of Florida.
. If FOR-THE PURPOSE Oi ENROLLING If FOR HOMESTEAD PURPOSES,
CHILDREN IN SCHOOL, PLEASE STATE PLEASE CHECK:
THEIR NAMES:
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I FURTHER CERTIFY that I will register at ~ local address when the registration books reopen, and oomp~j with aD
other requirements of a legal resident a~f this State.
I FURTHER CFR1'IF'Y that I have no intention to return to former domicile. and I intend to rrmain in
U C 1 E. ~ Count.
(lSt~)
Florida, permanenst,•.
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Sworn to = ~ ~ ' befar+e me this ~ da,T oI _ ~ ~
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_ ~ cu,cl`. . A.D.19~~ R/ue r~ f fl . S TAnK; e-
ROGER P01 TRAS, CLERK OF C IRCUI T COOT
ST. LUG1E COUNTY, fLOR1OA
EPUTY LERK c~ Q .
~b00~K~ '2148