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TO T!t& CI.EItK OF771E CIRCUPf CAU1tT. ~
ST. LuC 1 E courm, r•u~rnnA:
• Tl~is ia mr dcclaration ot Domicik ~nd Citizenship i~ tbe 5tate ot }~lorida that I am filing this day ia aceordsnee. am! ut
cvnlormitY rrith Section rl2.17. Florida Slatute~. • .
l wu (ormrrir a Mfial rrsideat oi ~d~:Y7~ ~~-l~ri~-~~ - / T and I
J Q17) (Stata)
residcd al ~~i! ~_~1•~ ~~~r ~ ~ - No~re~~er. I 6ave changrd my damicik to
(Sueet ud 1V~a0~r) ~f ~
and am and have beco a boaa fide resideat of the SUte ot Fbrida since c~~ day of
.19 ~ aod I reside at .
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~L ~.~-p~ 5T . LtIG 1 E County. Ffor;d..
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and this statcmeat is to be takea ~s mp dccluataa ot atiuaship. aetua! kgal rreidcace and domicik in tl~e Stste oi Ftorida.
- I F fOR TFtC PURP05C O~ ENROII tNG IF f
OR HOliE57tA0 PURPOSCS~
CHtLORCN IN SCkOOI~ PLE/1SE STAtE PLEASE CHECKI
THEfR,NAMCS:
f ~to ~e?=~ ~f~c~
. s~ iusa~ ~a~~rrr f«.
. _ ~ Fccr ^ =~»;R~s
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N~C!!A^.. Yc:f.ii£n
" - - D~cr 1b 2 ~4 PN 'TS ~
, 3~,q~52
• I Ft1H1'11FR CF.1iTIF} !ha! I tivi11 rcp,istcr at my loca! address wden the rcgi.ctratioa books rropcn, and comP~Y Witf~ nU
other rcquiremcnis of a(cP.l rrsidcnt uf this Stste.
- 1 FUIt :t CF tTI t st I c no intrntion lo rcturn to my lormcr domicilr, and 1 intcnd to rerruin in
~~'2'~~ c~,~~~~!/riC~~ $T . L U C 1 E _ County,
lCit~l .
florida, pcrmancmi~. ' _
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_ C•., SK•orn lo und suLscrit.rd F.cforc mc this < dsy ot /
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- ` f, ; ~ ST. LUG I C COUNTY, f lOR 1 UA .
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