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Declaration of Domicile and Citizenship u ~
X82'763
TO THE CLERK OF THE CIRCUIT COURT. i
ST. LUG 1 E COVIVTTn. FLOxID~:
Thin is my decoration of Domidls and Citisenship in the State at Florida that I am Siina this day is aoooedaoos. and is
oonfarmity with Section 222.17.1:7orida Statutes.
I was f
~ a legal resident of - - - ~ I
lab) 181ata)
resided at - However. I have changed ~ daniale to _
18t~t sari No~b~ .
and am and have been a bona fide resident of the State of Plaids since ~ ~''J' h ~ °f 1
i
_ 19~ and I reside at ~ o O ? ~ Ye H ~ e r8 ~ ~ 4
(8tre~t sad Noa+br)
~ } ~ P ~ c Yc ~ ST . L UG I E County, Florida.
lab)
and this statement is to be taken as soy deelaratiat of eitisenship. actual legal residenas and domieDe in the State of Florida.
'f
" IF FOR THE PURPOSE OP ENROLLING IF'~FOR HOMESTEAD PURPOSES,
CHILDREN IN SCHOOL, PLEASE STATE PLEASE CHECKS
THEIR NAMESS
~ IIPR I 1 PN 2 45
r . Etc
~ A
eiiit~
itEOM!! \'ER~tEO
482'763
-
f; -
I F[JRTIlER CERTIFY that I will register at my local address when the registration boob reopen. and comply with aD
other rcgninments of a legal resident at this State.
I FURTI~R CERTIFY that I have no intention to return to m~ former domie~7e. and I intend to remain in ~
County
J ~ ~ L~ V Y f L ~ i
Florida. permanensl; . -
,
. ice. J i
~ G~
- Sworn to and anbsen'bed before me this ~ day of ..~i ~ ! 33r~y #
[
A.D.18~.•~
ROGER I A CLERK OF CIRCUIT CO~dItT ~
ST. LUG i E COUNTY, f LOR t O
EPUTY LERK
. •
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