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Declaration of Domicile and Citizenship 1
4~~41~
TO THE CLERK OF THE CIRCUIT COURT.
ST. LUG 1 E COU~y, FLORIDA:
This is my declaration d Domic~7s and Citisenship in the State d Fbrida that I am filing this day in aooordance. and in
conformity with Section 222.17, Florida Statttee.
I was forme a bgal resident d 4~ ~ and I
p. (C1ity)~ (8tate)
raided at ~ ! ~ ~ ' However. I have my domiet7e to
18hwt aad Nambac)
and am and have been a bona fide resided d the State d Florida since ~y d
"~/ti is ~ and I reside at r
'l~ l
~ ~ 18tnet aadNambad
i ~Q ST. LUG i E qty,
ICib)
and this statement is to be taken as my declaration d eitisenship. actual legal residence and domicile in the State d Florida.
IF FOR THE PURPOSE OF ENROLLING IF FOR HOMESTEAD PURPOSES,
CHILDREN IN SCHOOL, PLEASE STATE PLEASE CHECK:
~ THEIR NAMES:
I~0 APR -9 III+ 11= ~
_ F~tLEU SEND RECTOII~t:9
5 ROGER POIN~i~A.
~IERK CMCUIT C T
a4cor~ ~~R~~ico
4~~41~t
i
p I FURTHER CERTIFY that I wSl register at my local address when the registration books reopen. and comp{y with aU
other requirements d a legal resident d this State.
E I FURTHER CERTIFY that I Gave no intenti~ to return tom former domia7e. and I intend to remain in i
i U C I E County,
Fbrida, permanentl; .
~t~ - ~ .
~
~i, ^~y-. " (Name)
_
n
_ ~ _
~ `i ~ 11:'i i Y tom.
'`~1'CSO~'~ ~ ~ (AddeMa)
Sworn to and snbaen'bed before me this ~ day d ~ ~ 'S ~
' ~ C
. A.D. lA, 8 O
ROGER P01 TRAS. CLERK OF C i RCU I T COtdRT J
o ~ MART/N
ST. LUG I E COUNTY, FLOR 10A ~ ~lq n e E. lyAR7; /v
y
BY:
E~
PUTY LERK
. 8~~9 P~ 25i
4 ..^.!1 F....., 7 ~ ~n