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TO THE CLERK OF THE CIRCUIT COUAT. 3156'~4
ST. LUC 1 E ~pU~y. g~,p~pA:
Tbis is nyr deelaratioa ot Domlctle aAd Citl~eosbip in the Stats of Ftorida tbat I~ filias this da,p in aeaordanos. and in
eoniocmit~ ~ritA Seetion 222.17. I~'{orZda Statu
I was t
r~ s legal ' ~ I•
1 1 18t~1
raided at Hawever, I b~ve _ehaaged m~? doeiaic~e to
(QtrNt aad N , ~
and am aad have beea a boaa tids resideat ot the St~ ot Ftorida staa ~J? ~
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~ 19~,.;~.. aad I reside a~C / Y
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ST. lUG 1 E ~„c~.
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and this stateaient js to be taken as m~p declanUoa ot dti:en~hip. sct~l legal res[deucs and doa~idle ia the State ot F1oTida.
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OR 'YHE., PURPOSE Of ENROII 1N~ I F i0R ~IOMESTEAp PURPOSES~
CHILDREN IN StHOOI~ EASE STATE ~ P~EASE CHEGK: ~
~tH N ES: ,
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fILEO AMD RECQRDEp '
. ~ St.IUC~E C~UNTY FtA. ~
ROOt€~ FOstRAS
- CL£Rl( CiRCU1T COIMT,~G~
- REr,oR~ v~~:F!EO..-_y~
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- Auc 18 11 oa AH'?5
- 3~156'~'4
I FURTIiEIt CERTIFY that I w~71 register at my lo¢ai addresa when the registntion booka reopen. and comply with aU
other requirements of s legal resident of t6is Statc. _
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I FUBTHE~ CERTIFY that I lutve no iatealion to return to m former domicile. and I intend to remnin ia .
• - _ - ~T . L U C 1 E , County,
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E Fbrida, permanemi; .
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~ Sworn lo and subscn'bed betore me thiu ~ a day ot ~
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E A.D.19 ~S
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g ROGER POITRAS, CLERK OF CIRCUIT COUtT
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~ ST. LUGIE GOUNTY, FLORIUA ~
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~ BY: -~i~
~ PUTY ~~RK .
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~ AGO F~'orm 71-~
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