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Declaration of Domicile and Citizenship
5:0140
TO THE CLERK OF THE CIRCUIT COURT.
ST . L UG I E COUNTY, ~,p~A;
This is mT declaration of IMmicde and Citizenship is the Sute of Fbrida that I am filing this dad in aoooa+danee. and in
oonformh~ with Section 222.17. Florida Statues.
Iwaaforme I alegal:~esidentof St.-~tc Col lens, i'ennsylvania ~I
lCIt7! {Stara)
resided at ~~ ~ t i? r r i s Street _ - However. I have changed mT domic77e to
{Street and Numbr!
and am and have been a bona fide resident oI the Sute oI Fbrida sinor J un ~ 3 , 19?O ~j ~
19 ?~~ -andIresideat 311 ~:outh ?th ~tr_'et
l8tnat sad Nrmbarl
.'or t ~i c r ce , ST . LUG I E Cannt~,)<'lori~da.
tC{bl
and this statement is to be taken as m7 declaration of citizenship. actual legal residence and domia7e im the State of Florida.
" If FOR THE PURPOSE OP ENROLLING
CHILDREN IN SCHOOL, PLEASE STATE
THEIR NAMES:
r ~_
if FOR HOMESTEAD PURPOSES,
PLEASE CHECK:
~9eo o~~ +o ~ ~ ~a
FlEE,Q ~~ f COAO{ 0
Si.t {E NTY.ItA.
ROGER P ITR1-5
CLERK CIRCUIT C
510140
I FURTHER CERTIFY that I ~ register at mT local address when the regstratioo books reopen. and oomph 'with all
other regniremeata of a legal resident of this State.
I FiJRZ'BER CERTIFY that I have no intention to return to mT former domie~'le. and I intend to remain in
-_-
a T . LUG 1 E Couat~.
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Florida, permanenti;,
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Sworn to and sabseribed before me this ~ daY of ~ o r t ' i c r c e r ~ 1 a . ?• 3 ~ ~ O
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ROGER PO 1 jRAS,. CLERK OF G 1 RCU I T COCdItT
ST. LUG I E COUNTY, f LOR 1 OA
BY:
. EPUTY LERK
BOOK34~ pa~E21T0
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