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Declaration of Domicile and Citizenship
4969'72
TO TH>; CLERK OF THE CIRCUIT COURT.
ST . L UC 1 E - COUNIR. FLORIDA:
This is my declaration of Domidle and Citi:easbip in the State of Florida that I am SHna this dq is accordance. and in
conformity with Sedioa 222.17. Florida Statutes.
I was former a kgal resident of ~C ~ F~~~ D f~ %i / ~ln ~ and I !
, ICl'Ryl - 18tatd
resided at .f 7~ ~ ~ /Yl ~ / ~71iG f
~f~,~.~n R (Z! However. I have changed my domide to
IStrMt asd Nam~rl -
and am and have been a bona fide resident of the State of Florida since ~ ~ ~7 ~ 1
19,.~~ and I reside at
18tr«t aed N
- ST . L UG I E qty, ~;da,
and this statement is to be taken as my decLntion of citisenship. actual legal residence and domidle in the State d 1!9oa~ida.
IF FOR THE PURPOSE OF ENROLLING IF FOR HOMESTEAD PURPOSES
CHILDREN IN SCHOOLr PLEASE STATE PLEASE CHECKS
THEIR NAMESS
.1 1980 ItU6 21 Pt4 2~ 1
F STI LUCC~ COlg1tY110E0 .
`r ilA.
t~o6ER POITRAS_ +
~ CLERK CIRCUIT C T~
-
- 4969'72 !
+
i
- !
li I F[TR1'IIER CERTIFY that I will register at my local address when the registration books reopen. and comply with all
other requirements of a kgal reside, of this State.
~ I FURTHER -CERTIFY that I have no inteOtlOn to return to my iormer domicile, aad I intend to remain in
? J T . Luc 1 E County.
_ ICrty)
Florida. permanenci; .
. ti r?:
(Naaw)
- ~ - K~~ h~rZL~
Sworn to and subscribed before me this ~ day of ~ .
~e C~~~J/l Qro 1~
R AS G ERK OF CIRCUIT COC~tT I
ST. I E COUNTY FLOR 1 OA - - -
•
_ " BY: _
EPU r K
- - - - _ X337 P~ 35[} .
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