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Declaration of Domicile and Citizenshi
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496961
TO THE CLERK OF THE GIItC'tJIT OOURT.
i
ST. LUG I E ppU~y, FI,pRIDA;
This is my deeluation of Domiede gad (3tisenship in the State of Florida that i am filing this day m aooordsaoe, and lr~ ; s
ooniormity with Section 222.17. Flosrida Statutes.
i
I was formers a legal resident of e - ~ and I
1, Iqt~)
resided at ~_s~f
~ 7 hM D t ~ ~ r ~ - However. I have changed m,T domiea~e to
18trM.od Nombw)
and am and have been a bona Sde resident of the State of Florida since ~y ~ j
. ~ ~ '
19 ~J _ and I reside at
- lBgwt gad Namb~r)
o u~ ; ~ ST. LUG I E County. Florida,
lGb)
a~ t~ Y ayt`c~.°uut ~ iii w t
i~vn ~r~ d~.~~~..~n i~ R~~}}}~, f~~~~ P'e~~~ ~lf~.l~ aM~ l7Atll~ 1~ ~ O~i!e ~ t l[8'N3i.
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IF FOR THE PURPOSE OP ENROLLING IF FOR HOMESTEAD PURPOSES,
CHILDREN IN SCHOOL, PLEASE STATE PLEASE CHECK:
THEIR NAMES:
1980 pUr, 21 PI# i2 12
_ ~ons~~ntG M •~C~rsort S i
n faEe aHe FECOROCo
a w n M /a r S o~ S - S ROGER
POITRAS~ '
CLERK CIRCUIT COURT
496961 r
I FURTHER CERTII~'Y that I w~ register at my local address when the registration boob reopen. and comply with aD
other regninme~s of a legal reaide~ aI this State.
f
~ I FURTHER -CER'TIF'Y that I have no intention to return to my for~mer~~. and I intend to remain in
_ -
i. L v ~ c -County.
(ate) •
FlOrlda, permanent)
j .
~ _
(N.m.)
- ~ cw~•••)
~ sworn to and subsen'bed before me this _L_ day of
A.D.1
R I S C ERK OF CIRCUIT ~Ot~tT
ST. LUG I E COUNTY, FLOR 1 A ~
• s
w
EPUTY LERK ~ `
.
Bt~~~ P1~GE ~ ~
. iM
- ~ i
Aril Form 7l 71
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