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('Uli,v l~l , t~ LUttli)A:
- 11ii. i; iny ~Irrl:nati~,n ~~1~ 1)c~tnic•+I: an~i ('itizr!~shi;~ in tl~~~ Statc uf I~Ic~ri~la Ui.~t t am l~ilin~ tlii~ clay in
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arcor~lancc.:uul in cunC~~rmit~r ~~~ith S~c~i~,ii "?.17, i=ioricta Stalutc~.
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1 was fc,nncrly a Ic ~al resi~lrnt of . - • and 1
(.~~y) (State)
r~sidcd at .~lP_~_~~~~~~~~-'~~---~-~~'---- . Howcvrr, 1 havc changed my domicilc to _
- ~ (~trret and Numh~r)
and ai ~ ai~d have b~en a boi~a fieir rrtii.f:~nt of thc State of f~lorid:i sincc . day of
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_ - - • ~ - ~?i~d ) Jcc~utc at ~ /~2~ `V~ ' -
(S1 and Number)
` St. Lucie
~ Cotmty, i'lorida,
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~Ci1y) 7
and this st.~temcnt is ta be takrn as my d::cl3ration of citizcnship, actual legal r~sidence and domicile in the- State ~
o~' Ciorida.
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(Inseri here any prrtinrnt facts, such •rs :alr ~~f property ar busirta~s, or relinquishment of employment at former
domicile, removal of familt• to ne~v dc~n~ieile, purcha.e uf home, rtc J
Entering children in school:
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~WCIE COfIN~
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KC RCIMT~~~OWtT ~1~
RECORa YERIFIEO.:...~,,,~; °
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I FU1tTHt:R CERTIFY that t~ti~ill register at my locat address ~vhcn the rcbistration books rcoren, anu
comply with all other rcquirements of a le~al residcnt of this State. •
I FURTHF,R ClsRTIFY that 1 havc no intention to return to my fonner domicile, ancl I intend to remain in
.,~c:ei't/r-~ - ~t . _Lucie County,
Florida, pcrn~anen'tly.
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E (Tu br r~rc!itcJ in ilni~l~~ :H~• :~uJ nn; i~~.d ,•d ~+~th (7:~{, t'ircuit ('„url. anJ Jupli~ atr ~~ilh ~aa A~cc~s~~r)
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