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Deciarat~on of Domicile and Citizenship
4969'70
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TO TAti CLERK OF THE CfRCUIT COURT. .
ST. LUC 1 E _ OOUNTY. FLORIDA:
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This is wy declaration of Domicile and Gtiti:enship is the State d Florida that I am Suns this day is accordance. and in
conformity with Saetioa 2?1.17. Florida Statutes. '
I was forme a legal resident d - • ~ ~ and I •
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resided at Aowever. I have cbaaged my domic~7e to ~ ,
18treet said Namber) _
and am sad have bee bons Sde resident of the State d Florida since ~ ~ day of
19 and I reside at ~
S. • LV C ST. LUG I E County, Floras,
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and this statement is to be taken as my deeLration d eitisenahip. actual legal residence and domicRe is the State d Florida.
IF FOR THE PURPOSE OF ENROLLING IF FOR HOMESTEAD PURPOSES,
CHILDREN IN SCHOOL, PLEASE STATE PLEASE CHECKS
THEIR NAMESS
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1930 AElS 21 P!i 2~ i 1
_ ~r FILED 1~N0ppF~~ECOROEO
5 ROGER
POITRASA•
CLERK CIRCUIT LOUR r
4969'70 f
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I F(JRTHER CERTIFY that I w~71 register st my local address when the registration books reopen. and comply with all
other requirements d a legal resident d this State.
I FURTHER -CERTII~R that I have no intention to ntnrn tom former domicile. and I intend to amain in '
U C 1 E County.
_ Cit7) -
F)orida. permanenti; .
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..Z~ ' ~ Lt`s `
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~ ; ~1~ ' ~ (Name)
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. ~ ~ before me this day d
.ROGER POITRAS. CLERK OF CIRCUIT COtdItT S C~'S~~ ~
ST. LUG i E. COUNTY, fLOR 1 OA -
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BY: ~ _ ~
EPUTY LERK ~
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