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TO THE CL~RK Ol~` THE CIItCU1T COUAT.
srs ~ uc ~ e oovrrr~r, Fz.onm~: . .
Tbls b m~r declaraliot~ oi Domtclle and Citlunship in tbs Stato ot 1~'to~rida tluit 1 am tiliu~ tbis dyr iA sccord~nee. u+d ia ,
tontormity with S~ctiun 222.17. Florida Statutcs. ~ ~
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l was torm~rty a kgal restdcnt oi t~ j/~ and I •
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residcd at ~ Howevor. t have changcd n~? domicilo to
t8tewt um0er) • .
aad am ~ad h~vo beeo i bon~ fide reaident ot lhe St~to of Florida siace day ot
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19 aad I reside at
~ l8trat ~nd Numeer)
. ST. lUG i E • Coun~y. Fbrida.
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and this atalement is to be takea u.mr declaration oi cittzenship. actual kgal residence and domicile in the Sta?te ot Florida. .
IF POR tHE PURPOSE OP EltROLLING - If FOR HOHE57EAD PURPOSES~
CHIL~REN IN SCHOOL~ P~EASE STA7E PLEASE CHECKt ~
7 IR NAHESt
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v 315428 .
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1 FURT}IER CERTIFY tbat I will rcgi.~ter at my lacal sddress when the registrution boaks reopen. and comply with all
' othcr requirements ot a Icgal resident of lhis State.
1 FU TItE~ I:RTIF hat ~ have no intention to rcturn to my lormcr domicile. and I intcnd lo remain in
' ~ ST . L U C 1 E ~ . Caunly.
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~ Florida. permancnti; . '
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F Swo~!l~.~6~q . ~c[orn mo this day of
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, ROGFR O R/lS„ CI_~RK OF I RC U i T COUZT
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