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Decl~ration c~f Dom~cile and Citiaenship '
TO THE CLEAK OF THE CIBCUIT COURT. ~4S'a~
ST. LIJG i E ~pU~y. ~,pg~~: _ •
Tbis b aUr deelaration ot Domiclk aad C3t~eashIp ia tbe State ol I~'lo~rida that I am 6~n~ tbis da,~r ia aoooeda~os. aad ia ;
ooatormity ~ritb Seetioa 222.17. F'lorida S
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. I ~ras tarnter a legal resident ot j~~~~='-~'~~~ aud I
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~OwQYe1'~ I baw eLaaged uu? doc~le to
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aod am aad bsve beea a boaa 6de resideat of tbs State ot Flodda aina dq? oI
7 ~~~A , % .19~ ~ . and I e+esids at ~_~-~~-~~-A. _ •
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and thi~ statement b to be taken as my deelantan at eittunship. aetual kgal residenos and domieile in the State of Flo~ida. ~
IP iOR THE PURPOSE OF ENROLLING IP POR HQMESTEAO PURPOSES~
CHILOREN IN SCHOOL~ PLEASE STAtE PLEASE CHECKt
THEIR NAMESS. . ~ ;
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4 I FUIt1'HER CERTIFY that I w~l register at m~ kul address ~vhen t6e ngistratioa booi~a reopen, and eompfy ~?it6 all
~ other requirements of a kgal resident of this State.
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i I~ THER CEBTIFY tlut I have no inteation to return to m forrn~r domicib. and I intead to remain im ~
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~ Sworn to d subscribed before me thls day of
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~ A.D.19 76
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~ ROGER POiTRAS, CLERK OF CIRCU{T COl~2T
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~ ST. L UC I. E COUN TY, F LOR 1 UA -
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E Y L E R!K F O~~~"'
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