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TO TNE CI.ERK Or' THE C1RCUlT COURT. v~~ ~
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ST. LUC 1 E CoUNTY. FLORIDA: t
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This is my declaratioo o[ Domicile and Citizenship in the Stato o[ ~lorida that I am filing thi~ day in accordance. end in `
conformity with Section 222.17~ Florids St~tute~. ~
1 was tormcrlv a legal residcnt ot tY and I - ~
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residcd at' ~ Howevcr. I hava changed my domicilc to
(Stieet and NumEer) ~ • '
and am and hnve becn s bona lide residcnt of the St~?tc of Florida since 1 L/ dsy ot
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.19 7.~ . ~nd I reside at ~ ~ ~
i , • , lStreet.ndNumber)
C~~ ~ ST. LUC 1 E County, Fiorida,
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and this stalement is to bc taken as my declar~tion o! titizcnship. nctual lcgal residenec and domicilc in the Statc of Fturide.
IF FOR THE PURPOSE Of ENROLIING . If
FOR HOHES7E/1D PURPOSES~ ,
CHII~REN IN SCHOOL~ PLEASE STATE PIEASE CNECK: ~
7HEIR NAMES2
,lr~J .c .L-L~ G~m:J ~ " -
~ XI ~~~t~-#J F LEU aN^ R~CORDED
S~. IUC~E COUNTY FLA.
ROC_h POiTR~S
CLERK CI.~CUIT COURT ~C~
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I FUltT1IER CF.RTIFl' tha~ I~~~ill rc•y,istcr at m~ local address when thc regisiration b«~ks reopen, and compl~• ~vit?~ all
~ o~i~cr rcnuiremt•r~ts of a I~E;..1 residcnt ot il~is Slatc.
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~ I I'URTj~ CER~Y lh. t I hx~•c no intentio~~ tu return tu my fornur domicilc, and I ir.tcn3 t~ rctinai:i in
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