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Declaration of Domicile a d p
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ToTaECL>~tx oFTHE C>RCtnTOOVRT.
ST. L UG I E - _ - COUNTY. FLORIDA:
This ~ mT declaration d Danidb and (hti:enship in the State d Florida that I am SWIE this dq in aoooedance. and in
oodarmltT with Section 222.17. Fbrida Statutes.
I was f a legal resident d ~ _ H % C1- l7 A /'YI l4 and I 1
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resided at ~ However. I have changed uqr domia7e to
t8tewt sad NasiDK)
and am and have been a bona fide;esident d the State d Florida ainoe ~ ~ ~ d
-~l .19~C' . and I reside at ~1 7
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lBteMt na NamDal
~S`T .t C'/'2__ ST. LUG I E - t;olmtT.1:'ioeida.
taal
and this stateme~ is to be taken as mT declaration d ettbenship. actual legal residsnoa and domiclk in the Slats d 1:'loeida. ~
" IF FOR THE PURPOSE OF ENROILiNG IF FOR HOMESTEAD PURPOSES,
CHILDREN IN SCHOOL, PLEASE STATE PLEASE CHECK:
THEIR NAMESS
IR80 APR I_ I PII 12~ 04 y
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I FIJRTHEA CERTIFY that I w1U register at mT local address when the registration books reopen. and compb? with all
other requirements d a legal resident d this State. {
I FURTHER CERTII~~ thst I have no intention to return to mT former domia'le. aad I Intend to remain in
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Florida. permanead; .
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Sworn to aad subeerl'bed before me this dad d
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ROGER PO1 TRAS. CLERK OF C IRGUi T COCdF2T
ST. LUGIE COUNTY, FLORIDA -
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EPUTY t.ERK ~ .
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