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Declaration of Domicile and Citizenship
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TO THE CLERK OF THE CIRCUIT COURT. .
ST. LUG 1 E COUIV'i'Y. FLORIDA:
This is my declaration of Domic7e and Citisenship in the State of Florida flat I am filing this day in accordance. and in
conformity with Sectioa 222.17. Florida Statutes. - .
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I was former a legal resident of `L° Y . /~~w / and I
(City) eBtaW
resided at J
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~ .However, I have co.~e3 ru d3mia'!a Lo -
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and am aad have been a bona fide resident of the State of Fbrida ainee ~ 7 7'`~ " daj of
,~4-~'L' ~ .198d - and I reside at 8'~'~ S/r19 ~"a- y ~i; • Y~/~? ~c~r~
and NombN
ST. LUG 1 E qty,
IAty~
and this statement is to be taken as my declaration of eitiunship. actual legal residence and domicfie in the Stite of Florida.
- IF fOR THE PURPOSE OF ENROLLING IF iOR HOMESTEAD PURPOSES,
CHILDREN IN SCHOOL, PLEASE STATE PLEAgE Cf1ECKS I^ ,r-"~
THE 1 R N/1MES: ~ ^ 1
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- _ !9~ HAR 24 ~ f 5
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I FURTHER CERTIFY that I will register at my 1oea1 addreas when the registration books reopen. and Comply with ad
other requirements of a legal resident of this State.
I FvR1`I~R CERTIFY that I have no intention to return tom former domicile. and I intend to remain in
UCIE ~~ty~
((Sty) _
Florida. permanensi; .
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Swore to and su before me this day of (Added 3 S,
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G~~ A.D.19 V~ F X01 ~ .~2n,~vt-w
ROGER P01 TRAS. CLERK OF CIRCUIT CO~dItT
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ST. L COUNTY, FOR 1~OA -
EPUTY LERK * ~
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~ AGO Form 11-72 3
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