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Declarat~on of Dornic~le and C~t~zensh~p
TO THE CI.ERK OF THE CIRCUIT COURT. ~~2~1'~2 ~
ST. LUC 1 E CpUt~rt~r~ F'I,ORIDA:
1
This is my declaratioa ot Domkile and Cit3zenahip in tbe State ot ~'lorida that I am Wing this day ia uoocdance. and ta
eontormity with Section 222.17; Florida Statuu:s.
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G~s . . ~r .
I was for~ v a legal resident ot ~~~/~/il
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resided at ~l 'C,~'~ ~/~v ~ 5 7~ . _ However. I have changed c~y domicik to
l&~wt ~ad Numb~rl . `
and am and have beea a bona tde resident t?f the State ot F'lorids sinee ~ I, d~l? ~
_.19 - aad I reside at - lo r- r._
~ ^ csc~.c.oaN~?
--~---r- /,F ~ C~ ~ ST . L UC I E Councy. Ftorida, .
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Sila LII~S S~iLlRlCp~ ~S LO bE ti~CCil ~S ti1~i aE~CIilil~lOA OI G~IZERlIUp. actuai legal residence and domieik ia the State of Fbrids.
~ IF FOR TNE PURPOSE OP ENROIItNG IF FOR HOHEStEAD PURPOSES~
CHILOREN IN SCHOOL~ PLEASE STATE PLEASE CHECKS ~
TH IR NAMESt
~ ~ ~ ~'LG
- fT.
LUC~E ~9U~TYR~~A.
C~~RK ClRCUtj ~pU~
~f CQRD v~o~ f1Ep.,~,~~
~M S ~ I 59 AN ~1~
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~ I FURTHER CERTIFY that I will register st my local address when the registration books reopen. and comply with all
~ other requirements of a legal resident ot this State.
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! I FURT ~ T1FY thtt I have no int,ention to return to my former domicile. and I intend to remain in
~ ~ ~i ~ r(' ~ $T . L UC 1 E . County.
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~ Florida. permanenii; .
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~ Sworn to and subscribed betore mc this day of `T / E' • ~
~
~ . A.D. l9
~ 6 ,
~ R ER P01 TRA . CLERK OF C IRCUI T COl~2T
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~ ST. LUG I E COUNTY, FI.OR i UA ~
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~ BY: ~
~ PUTY LERK ~~~K~~~~ f~i
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