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Declaration of Damicile and Citizenship
. 3158~.4
TOTH~ CI.ERK OF TAE C1RCUIT COUAT.
ST. LUC 1 E apUNTY. FLOAIDAs .
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This is my declsration ot Donsldi~ aad C.~i~easbip i~ t~ Stats o! FEorida I a~ ~ Lb1s dyr ia a~dana. ~nd is
oooformity ~rIW S~etba ?28.17. Florids Statut~.
I~ras i rn ci a k~l reddeat ol Yb ~2~ P
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1 ~~ioM?erer. I Aav~ ebanaed nqr donakite to
(8ttr~t w~ N~lK) ~ ' _
~l ~m apd b~ve baea s boat tide cesjdeat oi tbe Stats ot I~'loeida staee ~+U~ ~
1~ and I reside at • ' .
18te~wt a~ N
~ ' ST. LUG 1 E ~ty. ~
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ard t~s statement h to be talcen aa m~? dselnratioa o[ eit3zeoship. ~etwl kgal residenoe and domidle in the 3tate ot I~lorid~?.
I~ FOR THE PURPOSE OP tNROI.tING ~ If POR HOMESTEAD PURPOSES~
CHIIOREN IN SCHOO~~ PLEASE S7ATE PLEASE CNECK! ~
YHEIR MANE9: - ~
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FILEO AN~ flECJRUE~ _
ST.ll~i.~r: 40UktT ftA._ .
R4~i=e ?C~ 3AS
C~ERK L'; <;~ii yGURt L
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SEP ~ ~ 43 ~'~~J
315l~~4
I FilR7`HEIt CERTIFY that I w~l register at my lo~:at address w?hen the registration b~wka reopen. and eomply with aU
other requireiaents ot a{egal nsideot of this State. -
I FUB7'fiE,~~y RTIFY no mtcntion to retura to m former donucile. and I intend to remain in
• /~/./o2~/f' , ~T . L ut1 E , County,
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Florida. permanentl~ . .
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Sw orn to and subscribed betore me ~his day ot ~„T ~ ~
A.D. l9_ ~
ROGER P01 TRAS~ CLERK Of C IRCUI T COl~2T
ST. LUGIE COUNTY, Ftat~aa
BYt
EPIITY IERK
, 600!( ~~c~ PAGE / ,
ACO F.?rm 4t •22
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