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Deciara#~on of Domicile and C~#izensh~p
4'79230 -
TO THE CLERK OF THE CIRCUIT COURT,
ST . L l1G I E coUNTY, FLORIDA:
This is my declaration of Domicsle and Citizenship is the State of Florida that I am filing this day in accordance. and in
conformity with Section 222.17. Florida Statutes.
I was formerl a legs] resident of `rCt7~lL~ ~ and I
I(.tit~l
resided at v > ~ S ` ~ . However. I have changed my domiel7e to
(8tred aad NumDK)
and am and have been a bona fide resident of the State of Florida sil?ce d r~7.~,~ ~y ~
~ 19 and I reside at ~ a ~E'1 Sc~ ~ ~ ~~'~j-~-
(steed and I~nme.rl
~ • _ S T . L UG I E County. Florida,
Ill
and this statement is to be taken as my declaration of eitiseaship. actual legal reaidenoe and domicile in the State of Florida.
_ IF FOR THE PURPOSE OF ENROLLING IF FOR HONESTEAO PURPOSES,
CHIt.OREN IN SCHOOL, PLEASE STATE Pt.EASE CHECKS
THEIR -NAMESS
~C,~/
f9B0 NAR 12 PK I ~ 4
S?
IUCIE COt1NCTY.FIA.
ROGER POITRAS
q.ERK CIRCUIT COU T~
fiEC4~A VE.RIfIFC
4'79230
I FURTHER CERTIFY that I will register at my local address when the registration books reopen, and comply with all
other requirements of a legal resident of this State.
I FURTHER CERTIFY that I have no intention to return tom former domicde. aad I intend to remain in
i e ' T~ L V V I L COUnty,
r _ -
ICrt~I
E Florida, permanents; .
-
tNams)
4 ~
(Address) .
Sgrorn to aadsu~iacrabed before me this / dsy of
~ ~ l~~ J
ROGER POI IRAS, GIERK OF G IRGUI T COtd2T
ST. LUGIE COUNTY, FLORIDA
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e~~x 3~7 p~~ 780
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