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Declaration of Domicile and Citizenship '
495624
TO THE CLERK OF THE CIItCU1T COURT.
ST. L UG I E COUlV't~Y. FLORIDA:
This is my deelaratioa of Domicile and Citizenship in the State of Florida that I am filing this day is aoeordanoe. and in
oonlormity with Section 2?1.17. Fbrida Statute:. ~
I was formerl a legal resident of - S ~ and I i
lC9tyl Ii~atal
resided at - However. I have changed my domide to
18traat and Nnmbar)
and am and have been a bona Sde resident of the State of Florida since ~y ~
3 ~C~C + 19 and I wide at B~t~o~'' ~ t
(Stmt and NamMir) '
~e QT Si .C uCiE _ ST . LUG I E qty,
. tact
and this statement is to be taken as my declaration of citizenship. actual legal residence and domia7e in the State of Florida.
IF FOR THE PURPOSE OF ENROLLING IF FOR HOMESTEAD PURPOSES,
CHILDREN IN SCHOOL, PLEASE STATE PLEASE CHECKS
THEIR NAMESS
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I I FURTHER CERTIFY that I will register at my local address when the registration books reopen. and comply with all
f other requirements of a legal resident of this State.
I FURTHER CERTIFY that I have no intention - to return to my former domicile, and I intend to remain in
U C 1 E -County.
_ (City) -
Florida, permanenti; . _
~ 1980 AUG -8 AM il= 32
~ FIlEO RNO ~ECOROfO
S ROGER
PO
RASA
CLERK CIRCUIT COUR
RECORO VERIrifO___~_
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495~b24
~ '.''"t°~ (Nam.
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Sworn to and subscribed before me this day of _ ~ ~
~l' ~'/E r~~
.ROGER POI TRAS. CLERK OF G iRGUI T COr~FtT .
ST . L UG i E COUNTY, f LOR 1 DA ~ - -
BY: ~
t i
PUTY LERK ~ (
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ItR~ PAGF ~
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