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L~~~I~r~~i~n of ~~~no~ile a~d Ci#iz~r~ship ~
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TO THE CI.ERk OF T1lE CIRCUI'I' COi1R'i`~
ST s l UC i E COUNTl'. FGORIDA:
Thls is my declaration of Domicilo ~nd Citizenship in the Stnte af Flor~dr. that I sm i'iling this d~y tn i~~~cordance. and In
conlormity with Scction 222.17~ Florida Si.~tutes. ~ - '
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I wa~ Iormerl n legal resident of ~ , and I
' ~ (C~ty) lStats)
~g;~ ~t ~ r i,.. o o~~ ~ t~ : However. I have changed my domicile to
(Strc~t and NumD~t1 ' ~
~nd am and havo been a bona Cde re~ident ot the SlAte of Fiorida si~nce ._„i~ Z.d?-" ~ 1 ~ day ot
.19~a and I reside at 2 ~l 1 Gi' Y~ e_ ~
( ~ad Plumber)
Lt G~~i ~ ST. LUC 1 E Couaty, Florids,
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~nd this atatement is tc~ be tdken as my declaration of citizenship~ actual ltgal re~idence And domleile in the Sia?te ot rl~rida. ~
` I~' FOR TH~ PURPOSE Of ENROLLING If FOR HOMES?EAD PURPOSES~-
CHILDREN IN SCHOOL~ PLEASE STATE ~~LEASE CHECK:
7HEIR NAMES: - ~
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E couw°~r~~~
. . . R~OER POItAAi
- ot,tpK c~acuir oau~tt '~~i _
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- I FURTIiER CERTIFY that 1 will :egister at my local address when the registration books reopen. And comply with uU -
_ other requirements of s lesnl resident of this State. , ~
~ I FURTNEZ CFRTIFY that I have no intention to return to my former domicile, and I int~nd to remain in _ ~
• r~ . .L u c ~ - , _ Sr . ~ u c i e cou~ty,
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~ Florida, permanenci; . - . ~ ' "
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~%Si~'~~'t ' ;_~~b~T~bed before me this _ dav of ~J Y ~ ~j~, ~ ~ ~
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_ , A.D.19 .
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~ OGER POITRAS, GLERK OF CiRCUIT COURT ~ -
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~ ST . L11~'. I E GOUNTY, F~OR 1 UA ~
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AG:I Form 7l•?2