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• D~:~I~t`a~ld~~1 ~D~i ~Ot~i~i~~ ~1'1~ Ci~i~~~t~fll~ ,
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TO THE CLERK OF THE C1RCUIT COURT. ~
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ST. L UC I E ~pUtrrY. FLOItIDA:
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Thb b my dectuatlon ot Domicile aad Citiscnahip ia L1+e State oI Flosida that I am Qiag this d~r in aceordance. and ia
toaformitr with Sectioa 222.17. Florida Statutea.
' I wiu tormerl a k nsident ot ~l ~ V~Yt ~ i ~
, ~ ~qyl ~ IStatd
K~~ it n~~ ~ f' -~io~rever. I have changed m domieile to
18t~..t.ad N~mb.r) ' .
aad am aad have been a boaa Ctde resideat ot the State ot Florida since ~v h~ ~ day oi
l9~aadlresideat / C~veew ~ ~~iBr~~~ lo
(Sqwt a~d NumOsrl
~or r!~'vG ~ . ST. LUG I E Countr. Florida.
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snd this stateru~nt is to be taken u mr deelantloa of attzeaship. actual legal residenee and domicilo in the Stato of Fbrida.
~OR ~fi1E Pti~i'OS~ Oi` ~i~i~ot~iii~`. ~t3R iit3i~iE~T~Ati ~i)RPc"iSESi
CHILOREV iN SCHOUI~ P~~~S~ SiATE ~LEASE CHECKi
THEIR NAMESZ . ~ ~
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I R~GO~to YERI tEB
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I FURTNER CERTIFY that I will register at my local addnsa when the registration books nopen. and eomply with all
otber requirements ot a legsl resident of this State.
I F[JRTHE~ CEBTIFY that I have no iatention to return to my tormer domicile, and I IfIICAd to remain in
• ST . L U C 1 E , County.
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Florida, permanenti; .
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Sworn to ~nd subscribcd bcforo me this d~y ot 4~?~~ /-L~°t~,G e! ~ t~ 3~J
, ~~.L~-~ , A.D.19 7 6 - l.t~ ~
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R PO AS C ERK OF C IRCUI T COU2T ~
'"ST. LUGIE COUNTY, FIORiUA •
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BY: -
. EPUTY LERK fi F ~)~O ~~`Q
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