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TO THE C[,~;RK Ol~ TlIE CIRCUIT WURT. , E
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ST lUC 1 E c~OUN't'Y. FI.ORIDA: .
Th~i is my declaration o! Daakile and Citir.oaship ia the State ot Ftorida that I un i~ing thts da~r jn ~cwrdanee. at~d ta ,
eoatora~Ity with Secttoa 222.17, Florida Statutes. '
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I wa to~ a 1~~1 scsidcat oi snd I •
1 lStatel
rasidcd at ~ ~iowever. I b~vo cbanged m~r domlcile to
IBtn~t ~ad bKl •
~?dd un aad havc bcen a bona t'ide residcnt of the Slato ot Florida aIaoe day ot
19- ~ v ' ~ad I nstde ~t _ ~/x~~ 0' - ~ ~
(S_Nwt wd Nameer)
' • ST. LUC 1 E County. Florida,
~CIt71
uid tbts statcment is to be tak~n as an~r deetaratjon of eitizcnship. aclual kgal resideaee aad domic~c in the State ot Floride.
If FOR THE PURPOSE OP ENROLLiNG . IP iOR NOHESTEAO PURPOSES~
CHIIOREN IN SGNOOI~ PLEASE STAYE P~EASE CHECK: ~
THEIR NAMESS
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ER Ppl~'1lIAI.
RE ORD y ~~R~~ L
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I FURTNER CERTIFY tha~ I will regiMcr at my local addi~es~ whcn the regis;ntion books reopen. and comply with aU
othcr requiremenis of a Iegal resident of this Slale.
I FURTIiE~ CERTIFY that I have no int~ntion to return to my former domiu'le. and I intcnd to remain in
' ~ ST . L U C 1 E , Cc?unty.
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r'lorida, permanen~i; . ' -
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~ Swot n to ~nJ suburiLcd Lefore mo this ~ s day o( _
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; ROC,~R POI ns~ G~~RK OF C IRC I T COURT . I
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~ ST. LlK i C GOUNTY, f LOR 1 UA
~ BY: . .
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t'UTY I.ERK
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