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Deciarat~on of Domicile and Citizenst~i ~
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ST. LUC i E apv~y. ~,p~~:
Tf~ b aqr declu+~tioa ot Doenic~k ud Citlssas6ip is tM State ot I~'1o~id+~ t6at I am SW~ tut~ d~,~ ia a~eoo~daoa. aad in
eoatonottr with Seetion P22.17. I~'fo~ida 8tatut~s.
I aas i~ a ksat t'? Y L~ Y d~ 4e . V~- aad I
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rasided at Howewr. I luw ebaased uny do:aicile Lo
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uid stn aad bave beea a boaa tids resident o[tlis $eats c[I~'lo~rida sinos dq o[ .
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aad this statement Is to Ds Wcer~ u ay? de~eluatbn ot dtineaa6ip. actwl kgal t~esidenoe and dosnidie !n tbe 34te al Fiorida.
I~ i0R THE PURPOSE Oi ENROIIING IF FOR HOMESTEAO PURPOSES~
~ CHiIOREN IN SCHOOL~ PtEASE STATE -PLEASE C1lECKS ~
THEtR NAMESS .
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I FUBTHER CEBTIFY that I w~l register at my local addms when the tegistntion bodcs rcopen. aad eomply with a11
ot4e~ requirements o( s kgsl resideat ot this State.
I R CERTIFY tl~t I have ao iatrntion to return to my tormer domicik, and I 111LCOd to remain in
~ ' . Z Y C~ ~ L. ~ a, _ ST _ L U t I E Countr.
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Sworn to and ~ubscribed be[ore me this ~ day oi y!I !~'-,c l~-«/~~ ~lo ~
~ e'7n h r Y~ . A.D.19_L_5.
. ROGER P01 TRAS, CLERK OF G IRCUI T COl~2T
ST. LUGIE COUNTY, FlOR1D `
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EPUTY ~ERK
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