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t~~clara~~ar~. of Domici~Q and Citizens~ip -
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TOTIIE CLF.RI? OFTlIB QRCUIT COURT.
S7. L. UG 1 E CotlN1Y. Ft.oRIDA: .
~ T1~is is ~ny deefuataa ot Domin'le a+d GtiuasAip ia t?e State ot Pbtids that I aa fit~ tAb day is soo~d+nee. aad te .
-~ooformily vrith Sc~cttou ?~Z.IT. Florida Statntes. . .
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. 1~+as ta~ a kRal residcat ot 1 N~' S T e 1C , N~ l~/y
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• aad aw and ba~e besn ~ bona C?de resident ot tl~e State of Flotida since ~ A~ dap ot
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~ a.d l6is statea?cnc is to be takea .s m~r dedarstion d e~tiu,~s6ip~, aetwt kaat re~ideaoe and doaiw7e is tbe state ot Flaida.
• IF POR THE PURPOSt OP [NROi.~IkG Ii i4R NONESTEAp PURPOSES~
tNILOREN IN SCNOOL~ PLEASE StATE PI.EASE CHECKS ~Y-~.s~`I
~ TNEIR NAMES: ~ j.. ~
FI~.EO ~ND RECQRDE4
' . , ' i~. WCI: C01iNTY FLA. _
~ . ~ _ RG~E~ rSfj~AS
- CLEitK Cs~CUti COURT
' P.ECRRC VE^ ~'EQ
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• I FURTl1F.R CERTIFY thst I wip rs~ister at my beal addras wbcn the re~istrstioa books r~open. and eompl~ with all
~ other reqniremcnta ot a kgal midept ot this Statc. -
I FURTfiE~t CERTIFY tl~t I luvc ~o intcaiian to retnrn to m~r former domie~7e. and l intcnd to remain in
J~ • P I~E R t, ST . L U G! E ~„~y.
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Florida. pcra?ancati;. .
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~ ROGER POITRAS, CLE12K OF CIRCUIT CO T ~
• ST. LUCIE COUNTY, FtOR1DA .
BY:
~ CPUTY L' K ~
~ ACA t
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