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Declaration of Domicile and Citizenship
' S089S5
TO THE CLERK OF THE CIRCUIT COURT.
ST. LUC I E CpU~y, ~,p~A;
This b m,T declaration d Domicile and Citizenship in the State d Florida that I am it'tina this daT is acoordanoe. and in
ooniormit~ with Section ?22.1T. Florida Statutes.
I was Fortner a bgal resident d S " ~ ~7AQL-E / - / %~ `S~ and I
resided at y/~ Cam= /~'/~rY,fi, _ _ tc~crl ist~
and NebK)
However. I have changed tn, domide b
and am and have been a bona Ede resident d the State d Florida since ~~ ~~~y~~~ ~ ~ dq d
19~~ and I reside at ~ 3 ,El~ST C/9~'~ ~~ ~/~~
~% s`/ L. ~ ~-~~.- ~ ST. LUG I Eet,~..t.aaH~ CountT.Flor;da,
ux,~
and this statement is to be taken u m7 declaration d citizenship. actual bgal residence and domie~7e is the State d Florida.
" IF FOR THE PURPOSE OF ENROIIING
CHILDREN IN SCHOOL., PLEASE STATE
THEiR NAMESS
.~
IF FOR HOMESTEAD PURPOSES,
PLEASE CHECK:
X960 OEC -2 IW I~ 22
'ilEO ekC FECOgpfO
ST.tUC COINIIY.F A.
ROGE~ PWTRA~
CLERK CIRCUIT (~URT/f
RECCRn ~rRKrEn._._
509955
I FURT~R CER1')T'Y that I wiU ngtster at m7 bcal address when the registration books r~sopen. and eotttpb with aD
other tegttit+etnents d a bgal raside~ d this State.
I F[JRTAER CERTII~'Y that I have no intention to t+eturn to
Florida, permanenti; .
and I intend to remain is
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s~'J~•,: ~ _. „ '••-.-cam -.-~ .
Swarm to and snbseribed before the this daT d ~ `~1 ~,_ ~
R9~R POITRASj CLERK OF GIRGUIT COt~FtT ~N.~-~cti~~ i~u~~ifA
ST. LUGIE COUNTY, FLORIDA
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EPUTY t.ERK '
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