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Declaration of Domicile and Citizenshi t~~
P
49?.S0~T2
TO THE CLERK OF THE CIRCUIT COURT.
ST. LUCIC COUrITY, FLORinw:
- ,
This is my declaration of Domicile and Citizenship in the State at Florida that I am filns this day in aooordance, and in
conformity with Section 222.17. Fbrida Statutes.
I waa formed a legal resident of PR i /V C F / h' 6 ~ E / C K- ~1/1 iP Y ~ /+i ~ and I
I(~tty) (state)
resided:t ~f ~ o Y ~ ~ ~ _ However. I have changed my domicOe to
18tteat and Nambar)
and am and have been a bona fide resident of the State oiFlorida ainoe d+y ~
~~J/V F. _ 19 ~
~
- and I reside at =1 S
~ ~NE ~f'/E' S/ G L /1 0
( aad Nambel
~t ~ t u~ r c. _ ST. LUG I E qty, ,
(city)
and this statement is to be taken as my declaration of eitirenship. actual legal residence and domicile in the State d Florada.
IF FOR THE PURPOSE OF ENROIt.ING IF FOR HOMESTEAD PURPOSES,
CHILDREN IN SCHOOL, PLEASE STATE PLEASE CHECK:
THEI NAMES: .
. ~ S~- ,
.i~GQ~ GLt~~ t7~-~?'2aLt
~r
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I FURTHER CERTIFY that I wtU regi4ter at my Iocil address when the registration books reopen. and comply with aU
other requirements of a legal resident of this State.
~ I FURTHER CERTIFY that I have no intention to return to my former domicRe. and I intend to remain in
U C E County,
_ (City)
Florida. permanenu, . 4.~~~~`j
1980 dtlG -5 l~ ~ 5
C Ea~~€'~~"~~~.
t K C(RCtI~ CDt)RT
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L
aijj~~ -
i ~ 8 ~ ~ lwiaibed before me thi: S aay of ~ ~ ~~t L_ y f- r T L H. `
~ . ~~R AS C ERK OF L IRCUI T COt~F2T '
ST. L IE GOUWTY, fLORtO
- ~
BY: ~
EPUTY LERK ~ -
• t1R ~ P1GE -
coat . i
~Af;n p,.-~. 71.22
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