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D~cla~r~tiz~n af Dor~ni~ile ~n~d ~it~~~ns~~p ~
. ~ ~ ~ ~o.~~~~;
. . .
TO TIiE CLERK OF TNE CIRCUIT COURT,
_ $T~ LUC I E COUN'~Y~ ~'LORIDA: . .
This Is my declar~tion of DomIcite and Cili~enship In the State ot Fl~rida th~t I~m ~iling thls day in ~ccordance~ and in
conformit3 with Section 222.17. Floridn Statutes. ~
t
I w~s fo,,,~ erl a legal restdent ot C.;C~•` ~ and I
'c~y~ ls~aw) -
~iowover. I have changed my domicile to
(Strest sed Number). / ~
• u~d ~m nnd have been a bon~ fide rosidcnt of the State of Florida since daY o[
- 19~. and I restde at~ a ~
~ - ` , iSSie~t wd Nnmeez)
~ ~ ~ ST. LUC l E CouAty, F`lorida,
- .
_ . . ~c~cy)
and this statement is to be taken as my declaration of citaenship~ ~Mu~?1legnl ,residence and domicile Ia the State oi Flcrida.
IF~FOR THE PURPO$E OF-ENROLLING If FOR HOMESTEAO PURPOSES~
. CHILDREN !N SCHOOL~ PLEASE STA7E PLEIISE CHECK,
- - TH~1R NAMES: • ~ .
_ _ • 3 ~
~ - I FURTI~ER CERTIFY that I will register at my local-~ddress when the registralion books reopen. and comply with aA ~
other requirements of a legal resident of this State. ~ _ :
. - ;
- FUR HF, CERTIFI' that I hav na inte ion to return to my former domicile, and I intend to remain in i
: , S T. L u C i E , County, ~
~ (Git .
" Florida, permanenii; . - - - ' -
- ` 3~`~~~5 _ - -
? ~ca a+~a R€c R eo ~ - - - ~ ~
- ~ . s~. ~uc~~ covx~r ~t,~. '
C!E
KeCr~~~"1R~$ -
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- . RFCOR~ YEf~FiEp,~` - -
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t ti ` y L'' • s; . " . -
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~ i , ` 1 '•1 _ `~''{~~7~'~ ~ j . _
• _ _ (.E. ~ . ' / S _ / . -
- ,4~ j - - (Name) _ _
. . . r ~ _ _
( ~ ' ''~r ~ r-- (Addn~) :
~ ~.,~~•j.. . ~ , i
- ' Swotn to an scribeci hefore me this ~ p day ot d'G~ .~-LL~~~~50
-1-{-t.'~-- , A.D.19 75 _ _ -
ROGE 0! TR~S, ~LERK OF C I RCL i T GOUF2T ~ - ~ - ~
ST. Ll1G ~COUNTY, _ FLOR 1,UA ~ ~ ~
- ~Y : 7~~~~-{~ ~ - _ . -
EPUrY ~e~K
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~ ~OOK ~~iJ PAGE~~~~` - ~
AGO Form 71 [2