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TO Tll~ CL~RK OF`TliE CIRCUIT COURT, 32~~~ ~
. ST. LUC 1 E Courrry. Ft,OtttnA: -
This is my declaration ot Domicilo ~nd Cilhcaahip tn the Stulo ot b'lorid~ thal 1 nm t'~liag this day in aceordanco. and in ,
contormity with Srction r22.17. Florida Statutes. ' +
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1 waa ton~norl • kgal residcnt o! ~f3~L' G~4.~'7 F L/9 • and I
1~t71 (State) -
residcd at ~ ~ ~ 'v . C %
~~~jt~' ~ ~ . ];owever. I h~?vc changcd my dot~~icilo to ,
ISt~eet u~d Nva~ber) • ~ ~ .
and am ~nd h~ve becn ~ bona fide rrsident ot lhe Stuto oi Fiorida since ~ day ot
N~ ~ ~ 19 ZS ' and I reside at ~ S~ 5~ % t~1 ~
(Street and Number)
L~C ~ ~ ST . l. UG f E ~ Count Florida -
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and lAis slatement is to be leken ~s my dccli?ration o( citizcnship. aclual le~al r~sidunec and domieilc in thc Statc ot Floride.
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IF FOR THE PURPOSE OP ENROILiNG If fOR HOHES7EA0 PURPOSES~ '
CHiI'DR~N IH SCHOOL~ P~EASE STAYE PLtASE CHECK: J~
YHEIR NANESt ° I~1.
~f:ll~f U a re L ~:.;?u~1tiED
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RC:,EF PORit7~k~'S~,~~,~~
- ~IERK CiRO~IiT~:DlA~`7 V~`~
Pf~ORD vE ~ r~ ~£D.._..~.~L ~
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I FUI2T}IrR CERTIF'Y tha1. I will regi~tcr al my k~cal sddress wl~cn the registration bool:s reopen, and comply ~vith al!
uthcr requirements ot a legal residcnt of this Statc.
~ I FURTl1E:i CERTIF}~ that I havc no intrntion ta icturn to my formcr domicilc. and I intcnd to rcmai~ in
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€ 1'lorida. pcrrrnanemi;. ~ -
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~ Sworn lo nnJ sub~criLed :?efoic me ihix dny o( • =~-~~~-e- ~
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~ RnGER PO i TRAS.~CLF:RK OF G IRCUI T COUZT . j
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~ ST. LUC ! C COUNTY, f I.OR 1.UA ;
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