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Declaration of Domicile and Citizenship
48.3036
TO THE CLERK OF THE CIItCUIT OOURT. ~
ST. LUC I E oovluTY. FLORme: - -
This L aq deelaratioa d Domidk and Citiaenship in the State d Florida that I am SHoa this dq fa aoeordanoe, sad in
eontormity with Section ?12.17. Florida Statutes. f
. .
• r
I was f~ a legal resident d - ~ I
resided at However. I have changed z41 domicile to
f ass Naesatl ~ .
and am and have been a bona fide reside d the State dFlorida siaoe - day d
-19~ and I reside at ~n , :
~ ~ ~ .-~'-3
(tltnat sad
- ST. LUG I E county. Florin..
IQ4l
and this s4tement is to bs taken as my declaration d dtisenship. actual legal residence and domidle is the State d Florida.
" IF FOR THE PURPOSE OF ENROLLING IF FOR HOMESTEAD PURPOSES,
CHILDREN I.N SCHOOL, PLEASE STATE PLEASE CHECK:
THElR NAMES:
r 1980 APR ~ 5 AM tl~ 32
' S
Ra~6ERCP0IT .
RLEItK CIIlISI1T CO{pt
• - tRt~R! VERIFIED
483036
I F[1RTHER CERTIFY that I wRl register at my local address when the registration books reopen. and eompb with all
kE other requirements d a legal resident d this State. -
f I FURTHER CERTIFY that I hsve no intention to return to former domiu7e. and I intend to remain in
_ U 1 E County.
((Sty) -
Florids. permanend;.
J . t _
v~ :o
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U: _ cal
~!G s„Jn ~ ruy` • !y
`~F BOUNTY. ~'~P (rtaaM)
- Sworn to and sabeeribed before me this ~ day d s
~ ~ {
R ER AS CLERK OF CIRGUI T CO~dFtT .
ST. LUGIE COUNTY, ftOR10A - -
~ , 1
EPUTY LERK ~ 3
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