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Declaration of Dom~c~te and Citizenship
4'79625
TO THE CLERK OF THE CIRCUIT COURT.
ST. LUC 1 E COU~Y, FI.ORmA;
This is mT declaration of Domiea7e and Citizenship in the State of Florida that I am Sling this daT in accordance, and in
conformity with Section 222.17. F'lorlda Statutes.
I was formed a legal resident at ~Q ~ PP n n a and I
ICxt~l (State)
resided at ~ However. I have changed mfr domi~7e to
IStnet and Numeerl Q /
and am and have been a bona Gde resident of the State of Fbrida since ~ I (L~ ~ daT of
19~SQ.1L. sad I reside at ~ q nQ • ~ • ~ . S~ rl(~ I m ~z,
, ST. LUG I E
1041
and this statement is to betaken as my declaration of eitisenship, actual legal residence and domidk in the State of Florida.
- IF FOR THE PURPOSE OF ENROt.t.ING If fOR HOMESTEAD PURPOSES,
CHILDREN IN SCHOOL, PLEASE STATE PLEASE CHECK:
THEIR NAMESS
f 19~ MAR ~ 7 A11 2S
~ ~ P ~ )11 d i~- ~=~a.11.r t 11 rl F' K~ Yl EO A RE~C~p~Q
. ~RO~G~E~1'QOITRASA.
II.EJl1( CIRCIMT T~
REClt! YERIFIED..._ '
I
4'79625
dust re~e~veel ~us~ ocl o~ c°h? ~ .
I FURTHER CERTIFY that I w>71 ngisitr ai mT local addras when the registration boob reopen, and complT with all
other requirements of a legal resident of this State.
I FURTHER CERTIFY that I have ~ intention to return tom former domieQe. sad I intend to remain in
U C 1 E , ~tT,
ICtt~) -
Florida. permsneacl; .
..,1.j/)j~''j
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SWOln t0 and subscn"bed before me this I ~ daT Of ~ ~ (S`.(G ~ Q
mat C, a 3 ~ c ~ .c
- A.D.18.3~:.....: ~ ? CX
- - ~ , /
ROGER POITRAS~ CLERK OF G1RGU1 T COrdItT
ST. LUCIE COUNTY, f1.ORi0A
BY: ~ ~ ~ ~ .
E UTY t.ERK
a~~327 ~,~15~~3 ~ r -
.qf.~ For;n 7] 22
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