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7~0 THE CLERK OF THE CIRCUTT WURT.
- ST. ~UG I E couiv~~r. ~.oRmA: ' .
Thi.s is m~ declaration oi Domicile and Citizenship in tbe State of Florida thst 1 am filing this da~ in aocordaaoe, and in
conformit~ a-itb Section 222.17. Florida Statuees. ~ -
I R•as lormerlq a legal resident of n~' P~~ - , OI~,,L~ and I
t(sy1 IStat+1
res;ded at ~ ~~Q P/'YO e~ 4r . - Ho~ever.I bave ebanged aqy domicle to
IStrcet and hmabe~ -
a n d nm and ba~ e been a bona fide resident of t6e State oi Florida sina a~' asJ ~
~ ~ ~ ~/ ,19 7~. and I reside at /8~6 ~ /' e ~~• ~ ~
(Steeet and Number)
-~Do /' ~ S~. ~vCi •e _ ST. LUC 1 E CountT.F7orida.
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and this statement is to be taken as my declaration of eitizensbip. actual legal resideaee and domia'!e in the Stat~e oi FJorida.
" IF POR THE PURPOSE'Of ENROLLING
C1i1l~REN IN SCHOOL~ PLEASE STATE
THEIR NAMES:
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IP FOR HOHESTEAD-PURPOSES~~-
PLEASE CHECKS ~
1961 ,~A;i I 6 A'r~ I I~ I 8
FtLEC LhC ~! COH;~; p
ST. LUCfE COUNT Y. Ft A.
ROGER Pe1TRnS n
CLERK CiFCtl1 i COL'fiT //
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5i4U09
1 FLTRTI~R CERTIFY that I wi11 register at m~ local address when the registration boolcs reopen, and compl~ vvitb aII
E o~her requir~emenb oi a legal resident o! tbis State. .
I FURT'FiER CERTIFY thet I have no intcntion to retnrn to m~ former domiule, and I intend to remain in
~, ~- ~~ ,. ~~p - 5T , L U C 1 E , CountJ.
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~ Flo: idn, permaneDti~. ~
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Jc~E CCUNT'( •E~" . __~r- ~e~~~' ~ ~ ~~°To~
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S a oro to and subsrn'bed belore me this ~~O da~ ad ,
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~ ROGER PQITRAS* CLERK OF' CIRCUIT COC~2T
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ST. LUG 1 E COUNTY, fLOR 1 OA •
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EPUTY I.LERK
anoK~~~ ~'N~2818
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