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. Declaration of Domicile and Citizenship ~ ~
4969'71
TO THE CLERK OF TAE CIItCUIT COURT.
ST. LUG I E CovPITY~ FLORIDA:
This is m,T declaration d Dolmia'1e and Citizenship is the State of Fbrida that I am ~6 this dq in aooordanoe. and io
ooniormitJ with Section 2?2.17. Fbrida Statutes. .
I was former a legal resident d Tim Q ~a c _ fi~oi-i p~c~ and I t
1(St7) 1&at~l
resided st S~'.TD CtJ J- 9 /~~e - - However. l have changed m7 domide to
' (BtrMt asd Nomb~r)
and am and have been a bona fide resident d the State d Fbrida since 7~""-y - r ~ dad d
.Tyi?e 19 78 -and 1 reside at / 7Y3 E'/•~~ •-1' Tc.-r- .
(BteNt and Nambtl
,T
f .la c~ _ ST . L UG I E Cant. >c7arida.
Icx~,~
and this statement is to be taken as m~ declaration d eitisenship. adoal legal residence and domio'k is tha State d Fbrida.
If FOR THE PURPOSE OP ENROLLING If fOR HOMESTEAD PURPOSES,
CHIIOREN IN SCHOOL, PLEASE STATE PLEASE CHECK:
THEIR NAMESS
_ 19~ 11~ 2 ~ ~ ~ ~
`r F.ECOkOEQ
FIIE~A~ jy,ftA.
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f I FURTHER CERTII~'Y that 1 w~71 register at m~ loin address when the registration boob reopen. and aompl~ with ail
other regnireme~s d a legal resided d this State.
1
1 F[JRZ'HER CEftTII~'Y that I have no intention to return to m~ former domicile. and I intend to remain in
! U C 1 E - ConM~.
~T- Sy /~uc, t~~l
Florida. permaaenci; .
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Sworn to and snbscn'bed before me this ~ dad d /fir S T ~v~i~
A.D.1 ~
ROGER POITRAS. CLERK OF CIRCUIT COtdF2T -
ST. LUGIE~'GOUNIY, fLORtOA f
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K~~ PACE e~'!~ ~,i..~ ,