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TO THE CLEItK OF THE CIttCUTf OOURT.
ST. LUG 1 E ~;pU~y. }-j,p~A:
Tbis is my declaration ot Domicik and Citiseaship In lhe State ot b'lorida that I ua tiliag this da~ in aceordanes. and ia
ooatotcnIty writh Sectloa ?22.17. Fiorid~ Statu -
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I was torme a kgal seaideat oi and I
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resided at ~ However. I have cbaaged a~y domicik to
(aw~t.ed N.s~t) ~ .
~d ~a aad bave beeA s boaa flde reaident of~e Sbte ot Fbrida ainoe ~ da~r of
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19~ and I eesIde at
• (&awt Nusb~r)
, ST. LUG I E ~,,,t~.
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aad this statement is to be taken as m~r deciuat3on of citiuaship. actutl kgal reaidence and domie~7e In the State ot Fbrid~.
If fOR THE PURPOSE OF ENROLIING iF FOR ~OMESTEAD PURPOSES~
CHIIOREN iN SCHOOL~ Pl,EASE STATE PI.EASE CHECK: ~ ~
T~IE IR NANES: y
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I FURTHER CERTIFY lhat I will register at my local address when the registratioa books reopen. and comply with eiU
other requirements oi i legal resideat of tfiis State. •
I FURTHEZ C~ER7`F~~t I. havc no intention to mturn to my tormer damicile, and I intend to remain in
. ST . L UC 1 E . County.
1(Styf .
Florida. permanenti;. ~
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t~~$vy~~~ ~~~3u~bscribed t?efore me this ._.r.SQ, day of
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. A.D.19 ~ ~lf' ~ ~
ROGER PO AS GLERK OF C IRCUI T C4UEZT
ST. LUGIE COUNTY, F~ORIUA .
BY: -
E YY LERK
~ aooK 243 ~ 204
AGO F
orm 71 •2?
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