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•i~liis is ~t~y cl~cl:ii;~ti~~n nl 1)vmicilr an~f ('itiiri~;hiE~ in ihr St.itr i~f l~lorid:i that I am tilit~r tlii~ ~l.~y i~i
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accc~nl:~ucr, anii in ronfc~rmily~ with S~~rtion '~?.1'/, 1~lo~ida Stalutrs. t
1~vas fonn~rly a Ic~:ii rc~idrr.t c~l~ ~Gf/G~_ ancl I y
p~ ~ ~ lC~:y~ ~S ) `
r~si~lr~l at °_.r_---~e~1~c~G"----- -~~'cr ~s_. ..1-laa~cti~cr, I I1~ivC ChatlLi~ rtty domirilc t ~
' (Strr~t anal I~umArr) - :
a~~d 1Iri and 1r~~~r bcrn a bc~na (idi rctiiclen! of thc Statr uf l~lorida sinc~ day of
now /
- - - - , t9_~-3 , antt 1 /rrs~a~ :~c ._~a~~' _ ~0- ~-1 ~!'a -s~~--- ~
~ ` (SUtet ai~J Num
St. Lucie
~ ' -_lL•~~-H-~ - - - - _ Cotmly^ orida,
t~'~" )
and this statcm~iit is to br tak~n as my dcrlaration of citizcn~l~ip, actual lcgal residcn~ anc amicil~~ in thc tate
of Flarida. ~ ,
(Insrri hert any prrtinrnt facts, sucA as s:~ic of pruperty or businrss, or reGnyuLchment of employm t t fotmet
domicile, trmo~al uf family to nc~~ dosui~ilc, purahas. ut home, ric.)
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Entering children_in sctiool: ~ _ :
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- ~omus ~
st~wc c. ~curr eouxt
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~ 1 FURTtIFR C~RTIf~~' that ~ ti~~ill rc~ister at my loca! address ~~•hen the regisUat:on books reoprn, and ~
i comply witi~ ~~11 other req~~irLments of a le~ai r.si~leni of this Statc. .
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6 I rUR'I'HER CERTI = t.~t 1 havc nc~ i:~tcntion to rctur» to my formrr domicile, and 1 intcnd to mmain in
~ ~ ~ St. Lucie
` Cou nt y,
~ Florida, permancntly. (c~'y? ~ - - - - ,
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