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ST. LUCIG-_ - {
_ _ COUN~'Y, LUR11)A:
~l~is ~ is my d~:rl:iration of I)omicilc .~nd Citixcnship in th~ Statr of f lcxicla ihat ! am filinh this day in
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accc~rclancr, and in conl'orntity with Srrtion ?22.17, Florida Siatutcs.
1 was furmcrly lr~;al residcnt af ~'_1~ '4.~ . '`t and 1 r
(CitY) (Stalt) _
r~sici~d at --_-~-~~1-1~)t Ac~oc~!~~'~~?~_.~r Nowcvcr, 1 have chanFcci my domicilc to
(Strrct and !du~nbrr) t
and am and havc bc~n a bona fidr r~sid4nt of the Statc of ~lorida sincc _ ~~G ~ay of
/ ~ ~,f .F ~.0.~ s li E,~~ ~ 7'~.
_ z.,/f~r~! , 19_2~__, and 1 residc at
L~ / (S~rect and Numbrr)
_~Q_7 _ _~f __~_u~ic=
=--a------. ------St. Luci°------ County,Florida,
(CiIY~ 4
and tiiis statrmcnt is to hr taf:rn as my declar.~tion of citizcnsl~ip, actual Irgal residcnce and domicile in the State ~
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~,f Plorida. ~ E
(Inseri here •rny prrtirrul faclc, ~ucl~ u s.J~ uf prup~•rly or bu~inrss, ur rclinquishment uf rmployment st former '
domicilc, removal uf family tu ne~v domicil.. purchase ot home, rtc.) ~
~E~ITERI"'C CHILDRE:7 I',~ SCHOOL: HOr'~STEAD ElG?~iPTTU'~: ~
If enteritig children in school, ~
please 1 ist i;heir i~ames :
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. =TLI~iE Cdil~T~RfLA.
ROGE; P4tTitAS ~
~ CIEAK Ct~~U1T COURT
aF~na4 vER:=~FD
! .~w 31 10 a~ AM'75
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1 FUR7~HI:R CI:FtTIFY that 1 K-ill rcgistcr at my local address when thr rcgistration books reopen, and ,
com~~ly with all othcr rrq!iirrmcnts of a lc~al r~sident of this Stat~ _ 4
1 FURTHER Ct:RTIFY that 1 havc no intrntion to relarn to my form~r domicile, and I intc~~d to mmain in ;
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, _ ~ ~ ST. LL'CIE Count !
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}~loricla, p~rmancntly. cc""~
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~ Sworn to at~d~suU,~-cribed b~ fon• mc !}~is e~ da~~ of
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'•c~,~~'' A.D. 1 ~1__ ~ ~
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1Z 1I1~ C 1'E':iS
~ P(~I~`~I~~"~ ' C~i.L•'RK CTRCl17'r COUR'!'
~ i~ _ , I'lo,-ida
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~rN~rv ~ cxt tcd in Ju~~hi~fr ar.J uriM~m~l filr.! . ~'Irrk Circuit ('ow1..~oJ ~lu•,I~calc . : A~>cc~ut)
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