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Declaration of Domicile and Citizenship ~~
TO THE CLERK OF THE CIItCUIT OOURT. 509604
ST, LUG 1 E ~pUNTY. ~,pg~~;
This b m,7 declaration d Domiefle and Citisenahip m the State d Z'7orida tsat I am >~ tsb dq k aooordanoe. and k
conformft~ wits Section 2?1.17. Florida 8tatntea.
I was f ~r a legal resident d ~~~J ~ ~~ / // U • and I
~/,A/ IClt,~l - !elate)
eesided at ~ ~~ O Wg'~~ ~~`t= - However. I save esa>aged ~ domidle to
cet:..c.vaNr.>t.el
and am and have been a bona fide resident d tse State d F7ocids since dq d
_.11.x. and I eeaide at ~.S'I ~ C~~~/P ~ ~S~
• ceb..c a.d I~1e~bael
.~t~-co-t- ST. LUG 1 E ~ Via,
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and this statement b to bs taken as mT deeLration at eiti:enship. actual kcal residence and domicDe is ibe State d Floeida.
' IF FOR THE PURPOSE OF ENROLLING If FOR HOMESTEAD PURPOSES,
CH I t.DREN I N SCHOOL, PLEASE STATE PLEASE CHECK: I ` ~I
THEIR NAMES: ~~ 1
'~ t980 OfC -8 PM 12~ I S
~-. FILEO ANC FECOROfD
ST. LUCIE COON T Y. Fl A.
ROGER POITRAS
CLERK CIRCUIT_ Q
RCCQRD \'fRIFiE^_ T _
509604
I F1JRT~R CERTIFY teat I wit! regbter at s~ local adde+esa when the registration bodrs reopen. and compi~ wits aD
other regninments d a legal resident d tsb State.
I F11R1~R CERTIt'Y tsat I save no intention to >tattan to former domicile. and I intend to remain is
U C I E . CooatT.
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Florida. permanent!,'.
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Sworn to and snbevibed before me tsb ~ dad d ~ jtJ i ~.'' ~ R~ •D
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RQf i~R P01 TRAS. CLERK QF CIRCUIT CO~tT
~ ST. LUGIE COUNTY, fLORtOA
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BY: ~
~ EPUTY LERK
-344 P,~1305
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