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Declaration of Domicile and Citiiensf~ip
49'7244
TO TH>r CLERK OF THE CIRCUIT COURT.
ST . L UC 1 E Covrrr~r. FLOR>D~:
This is mT derLntion of Domict7e and Citizenship in the State of Fbrida tbat I am Sling this daT is aooordanoe. and in
conformity with Sediart 222.17. Florida Statutes.
I was former a legal resident of ~a .e % L A c~ ~ Q Gl /4 ~ ~ ~ o R ! d A and I
IcYt~l Istatel
resided at / ~ 9 G PA ~ ,Q~~ e - However. I have changes mF domic~e to
(Street and Nambarl
and am and Lave been a bona fide resident of the State.of Floridasince ~G daT of
_ ,19
~
U • sad I reside at ~ ~ ~ .-S P 1 p A s 1 V ~ e c.c~
n 18traat and Nambarl
1' O lz ~ S ~ ~ y Q . c _ ST . L UC I E Count. Florida.
1ix41 -
and this statement is to be taken as m~ decLntion of eitizemhip. aetnal legal residence and domidle in the State oI Florida.
IF FOR THE PURPOSE OF ENROLLING - IF FOR HOMESTEAD PURPOSES,
CHILDREN IN SCHOOL, PLEASE STATE PLEASE CHECKS ~ i
THEIR NANESS
- a
49'7244
. 1980 Al-"o 25 PM 2~ 36 -
- t 1tEO ANC ~~coaoe o
ST_LUCiE COUt1fY.Fl A.
ROGER POITi~AS
~ CLERK CIRCUIT COURT
I FURTHER CERTII~'Y that I wn11 register at m~ local address when the registration books reopen. and eampl~ with aD .
other requirements cf a legal resident of this State.
I F[JRTIIER CERTIFY that I have no intention to return tom former domicile. sad I imtend to remain in
u c 1 E , ~h.
lat~1
Florida. permanenti;.
'i,
III ~ i
i
r(.
_
= ~ _
IN ~
- ~
i Sworn tA~od wbarnbed before me this ~'y dad of
A.D.1 ~ CW~S t'U tJe ~l ~
l
P,OGER- POI AS, CLERK OF CIRCUIT COtdF2T
i
i ST. UC 1 E COUNTY, FLOR 1 DA -
• ~ 1
BY: ~ ~
PUTY LERK
'
_ ,
~ ~,.i ~
~:~337 PAS 751
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