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d~~cl~ra$ian ofi ~~m~c~t~ ar~~! C~to~~nshop
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TO TI~E CL.~;RK OR THE CIRCUIT COUIiT. 3~~ O
ST. LUC 1 E (~pV~y~ }1,pRIDA:
Tbis is my dcclanUoa ot Domicile and Cjthcnship in the Stato ot Fiorida that I am t~iag lbis day in aecordanco. ~nd in .
eoaformity rvilh Scctioa 2~.1T. Florida Statutes. ~
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I ws; t rmcrl • kgat residcnt of -~9~e:Q.~vn.~7 ~ 1
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residcd at _ ~ Zlowovcr. I hevic ebangcd my domicilc to
ISer.~t.nd Nuas~x) •
and am u~d havo bcea a bona lidc resideat o! the St~to of Florida since ~ day ot
19 ~ S and I res~de at ~ ~~~'7~~~- ~
• (Stre~t ~nd Numberl
• ST. LUG I E Couaty. F`lorida,
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and tbis statement is to be taken as m~r declaration oi citizenship. actual kg~l residence aad dotnicile in the State oi Florida.
IP FOR THE PURPOSE OF ENROLLING - I~' POR HOHESYEAD PURPOSES~
CHIL~REN IN SCHOOt~ PLE/1SE STATE PLEASE CNEC1:: ~
tNEI NAMES2
fiLEi 1?NO itEC+~6E~ ~3
iT_ L~CtE COilNTY f~A. d+
' ~p~~F.?piTAAS
CLfRK CIn:.UtT_. COURT
P.FCQRi1 VEf.:F1ED j
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I FURTHER CERTIFY that 1 will rcgi.~ter at my local address wl~en the registralion books reopen; and comp)p with all
! othcr requirements of a Icgal resident of this State. " " .
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C 1 FUR :t C TIF th I hsve no inttntion to rclurn to my former domicile. and I inicnd lo remain in
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~ Florida. permancn~i; .
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~ Sworn lo nn3 sub~criLcd bctoto me thi~ Z: dny of ~l3 7` ~c~t
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RnGfR P017 CIERK OF C I RClll T COU2T
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