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TO TIIE CLERK OF T!!~ CIRCUIT COURT~ , a3~03?~r '
ST. L~UC 1 E ~pUNTY. FLORIOA:
• This b my decluation ot Domtcile'~nd Citizonship i~ tho St~to o~ ~'lorida that I~m t~ling this da~r in accotd~nce. ~t~d in • ~
contornnity witA Scctioo ~.17, Florid~ Statutca.
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I wu tormcrl a legal resident ot ~-=A
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resWed at ~ • - HoMe~er, I Aave ebanged my domicilo to
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aad sm ind have been ~ bon~ tide resident oI thc State ot Florida since ~ c~ day ot
- - _ -19- - aad I reaide at ' ~ •
' ^ 13trwt sAd Nomberl
vl~~~,p . , ST. lUG 1 E County. Flocida.
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" arid tbia statemcnt is to bo taken w my dec4ratioa ot eitiscn~hip. aetual lcga! resideneo and domicile in tfie State ot Florid~.
IF FOR THE PURPOSE OP ENROLLING I~ fOR HONESTEAD PURPOSES~
CHIL~REN IN SCNOOL~ PLEASE STATE P~EASE CHECKt ~
TH R NAMES:
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f~E~ A110 RECORQEU
, fT.lrC1E GOUMtIf flA- C :
ROCfR ?OtTRAS
~ JA ~lfrR C~RCUIt COURT ~ ~
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I FURTIIER CERTIFY that I wil) register at my local addrcss when the registration books teopen. end compiy with all
~ other requiremcnts o[ a legal msident ot this Statc.
I I FURTlII~:;t CERT~IF
' thst I h~?vc n iatention to return to my former domicile, and 1 intend to rcmain ia
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~ Florids. pcrmnnen~i~. ~
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~ Sw•orn to and suh~oribc:d l,cfoFe nio ~"+i~i~ day ot ~ ~ '
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RQGER POI~R/1S~ CI.CRK OF C IRCUI 7 COURT
ST. LUG I~ COUNTY, FLOR 1,U/l ~
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