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Declaration of Domicile and C~tizensh~p
~ss~?s,S
TO THE CLERK OF THE CIRCUIT COURT.
ST. LUG I E Cp~y, ~,O~A:
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Thin is m~ declaration of Domir~7e and Citisenship in the State of Florida that I am Sting this dq in aeoordanoe. and in
aonfarmit~ with Section 222.17. Fbrida S4tutes.
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I was formerll a kgal resident of ~y ~ e~nV / ~ S • ~ • .and I
/1 ( p- I lW~) 1l3tatw)
resided at ~ t7 S ~R P aT lT 1 l~ /'2 /ICY . _ However. I have changed m~ domielle to
18ems~t aed Nambw)
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and am and have been a bona fide resident of the State of Fbrida since ~ / ? ~ ~7 ~
per` _ u c i~ ~ 1 V~ .
19 0 - and I reside at ~ ~ ~ ~OQT S 7r~
113trwt asd Nsssb~rl
RT T
. t,~ C ~ G ST . LUG I E ~ti.
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and this statement is to be fallen as m~ declaration of eitiunship. actual legal residence and domia`le in the State a[ Florida.
IF FOR THE PURPOSE OF ENROLLING IF FOR HOMESTEAD PURPOSES,
CHILDREN IN SCNOOI, PLEASE STATE PLEASE CHECK:
THEIR NAMES. I
~a ~ ~ RT ~tY cy ~ le~ ~f)U(~ J~
19fi0 AUG I I A!1 1~= 02
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FILED RNO F: CORDED '
St tICtECp~p~ 1Y.ilA.
ROGER POITRAS
CIERK CNtCWT C T
- RECCRC YEPfF1!'p~
4ys~ss
I I FURTHER CERTIFY that I will register at m~ local address when the registration books reopen. and compt~ with aD -
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
T. U C I E ~ Con~T,
_ ICitr!
¢ Florida. permaneuLi; .
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' c* _ - (Name)
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~~.=~~Memi~{4~-bea before me this aa~ of Pa ter' T. . I,~C. i t? a
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ROGER POITR S. CLERK OF CIRCUIT COtdRT
ST. IUGIE COUNTY, FLORIDA
3 BY:
~ _ ~
i EPUTY LERK -
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