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TO THE CLE:RK OF THE CIRCUIT COURT.
ST. Ll1C i E ~p~rrx~ F'I,ORIDA:
~ Thu Is my decl~ration ot Domicile and Citizen~hip io the State oi Florida that I am filing thu dap tn ~ccordance. snd in
eonfocmity M•ith Section ~2.17. Ftorida Statute~.
~ ~raa formcrlr a kgal re~ident ot ~ n2.~77`~d ~ and I
~pty? ISi.ul
resided it L~ /~l~ 1/j~-' ,,~'~,Q~ . - However.ll?ave changcd my domicik to .
(Str..t aad Nump.tl ~
and ua ~nd have ~een a boaa fide resideat ot the State ot Ftorida since day ot
/11'/__'L!~Rr'~-~--:19_~
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- and I reside at s~~ ? ~5 ,~=~.~,E'/>1/'L?~Q ~~L~~~l~-
(Stiwt ~ad Numbe~!
! J% C,(~ _ ST. Lt1C I E County. Florida,
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aad this statement is to be takea u my decLration of citizenahip. actual kgal residence aad doaucile in the State of Florida.
Ii fOR~THE PURPOSE Oi ENROLLING If FOR NOKESTEAD PURPOSES~
CHIIOREN IN SCHOOL~ PLEASE STATE P1,E11SE CNECK: ~
THEIR NANES2
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s I FUR'PHER CERTIFY that I w~l register at my local address when the registration books reopen, and comply with all
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; other requirements ot a legal resident ot this State.
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~ 1 FURTHEZ CER'TIFY thst I have n,o intention to nturn to m~ Iormer domicile. and I intend to remain in
; ~ i ~ .C~> C ! ~ , ST . L. U C t E . County,
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= Florida. permanen~i; .
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= Sw•orn nd subscribed betore me thia ~ day ot ~
Ct~Tz„~ ~~f'C' ~ 1~ ~ 2-~
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_ ~ . A.D.19~~ ~ -
- RO . R POi TF2ASL CLERK OF C{RCUI T COl~2T
ST. LUCIE COUNTY, fLORtUA ~
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BY: ~
EPUTY IERK ' ~
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