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Declaration of Domicile arid Citizenship
4968'75
TO THE CLERK OF THE CIRCUIT COURT.
ST. LUC I E COUN'TY~ ~,p~w;
This is mT deehiratioa of Domicile and Citizenship in the Scats of Florida that I am fi4aa this d~ is aoooadaaoe. and is
conformity wltb Section 222.17. Fbrida Statutes
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I was formed a legal resident of _L~C„~~~ r~P~~.v_~- sod I `
117) lBtaW I
resided at ~ .2 ~ ~ fib s ~~~a~ ~ Q~ - However. I have changed mT domicile to t
(Bank and Naafi) ~ ~ i
and am and have been a boas fide resident of the State aIFlorida since S dal ~
L ?3o yA.S'o4 ~ #
~f 19- ~O . and I reside at ~ ~ ~ s~~° T
~ ISteMt aad?:ambari
~"o ~ T' ~ ~..QiP ('..e ST. LUG I E ~ti.
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and this statement is to be taken as mT declaration of citizen:hip, actual legal residence and domiea7e in the State of Florida.
IF fOR THE PURPOSE Oi ENROLLING IF fOR HOMESTEAD PURPOSES,
CHIt.OREN IN SCHOOL, PLEASE STATE PLEASE CHECK:
THEIR NAMES:
180 Ate 20 Phi 3 03
- FIlEO AM~+•• ~ECOK4ED
SLLUCIE COtRlTY.FIA. I
ROGER POITRAS
CLERK CIRCUIT COURT ~ ~
RECGP.n vFRtftEO_~ -
• 4968'75
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I FURTHER CERTIFY that I w~11 register at mT !Deal address when the registration books reopen. and oomplT with all -
other regairements of a legal resident of this State.
I FURTHER CERTIFY that I have no intention to retarn tom former domia'le. and I -intend to remain in .
U C 1 E . CouMT.
ICrtr)
Florida, permanenu;.
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sworn to area subscribed before nx thi: ~ aaT of ~~-P~!'~t Or~~r , ~ 3 sue'
.w.n.1 ~ = J,gcti' h~. r1~cT~iv~s
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ROGER POI TRAS, CLERK OF CIRCUIT COC~tT
ST. LUG I E COUNTY, FLOR t_OA - - -
BY: : ~ ~ ` ~
-LTG EPUTY LERK ~
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• - - °337 PEE 189 '
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AGn Forn 71-71