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Declaration of Domicile and Citizenship
4968'76
TO THE CLERK OF THE CIItCU1T OOURT, .
ST. BUG I E Cpl1NTY. ~,p~A:
This is m7 detlantion d Domicile and (l'ttitenship in the State d Fbrida that I am 51ing this daT in aooordanoe. and in
oonformit~ with Section 222.17. Florida Statutes.
I was formed a legal resident of M ER R ~ TT I S L A M 3' 1~ r and I ,
1at71 19taW
resided st ~5a~-~~ ~ ~ q L EY CT - However. I have changed mT domxile to
(BtaMt sad IyamD~sl
and aR? and have been a bona fide resided o~i the State d Florida since . ~ daT at
19~ and I reside at l~ . ~ I~G~,PD(~T-
~Q
18srMtasdl~l
p0(iT' ,L~'~' 1.:UC1 ~ _ ST. LUG I E
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and tJtis statement is b be taken as m~ declaration d t3tisenship. actual legal r+ssidenee and domia7e in the State d 1:`locida.
IF FOR THE PURPOSE Oi ENROLLING IF fOR HONESTEAO PURPOSES, i
CHILDREN IN SCHOOt., PLEASE STATE PLEASE CHECK: ,
THEIR NAMES: i
_ ,t ~ ~o v ~ N ~~~Tno I+ F_ ~a~~~y I~ AU6 20 ~ ~ 04 ! -
- i'1tE0 ANC FECOKi~EO
AI )I C C nT~" ~~I~-~ E T ST.LUCIE CGUNTY.FIA.
ROGER POITRAS
CLERK CIRCWT COUR
RECGR~ ~ERIFtCO____- -
- 4868'76 '
I FURTHER CERTIFY that I w~71 register at mT local address when the registration boob reopen. and oomph with all
other requirements of a legal resident d this State.
I FIJRTAE$ CERTIFY that I have m intention to return b mT farmer~'cle. and I intend to remain in
, T. i_ u c t c _ Co~mg
tCit~) _ •
Florida, permanenu; .
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Swrorn to area subscribed before me this a ~ da, d # J
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ROGER P0ITRAS, CLERK OF CIRCUi T COtd2T
ST. LUGIE COUNTY, FLORiOA - - -
'
- - BY: w~-~
EPUTY IERK ~ -
~ - - _ B~oK337 PAGE l90 ~
• i Y
Aril F'~-m 71 ?2