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TO T'HE CLERK OF THE CIRCUtT COURT.
ST. LUG ! E CpUNTY~ F'LORIDA:
• Thu 1~ my dectaration ot Domtcile and CitizensAip tn the State o[ Florida that I~m Gliag this day in accordance. and tn
eontocmitY witA S~ct+on 2~.17. Flarida Statntes. C~
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- t ~va~ tarmerl a legsi naident ot ' {C~~ ~~r' - _ !~E" and I
ICWI ~ I~+al
resided at „~'~~'/"'E~~ i" ,~/~`l' ~2'l'Ct ~/E However, I have cAanged my domicile to ~
(3tn~t ~ad N~mb~r) ,
• % ~ ~ / Y~ day of
~nd sm and Aave beea a bona Cde resident ot the State oI Ftoridn since
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~ ~ 'i~ - 19 and I re~ids at ~ ' ~ ~ ~!1 - ~ ~ ~ ~
(SttNt and Nua~Der)
~7<. /iL/'~ ~ , ST. LUG I E Co~,acy. Florida.
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and this statemeat u to be takea s~ my declacation ot eiti:enship. adua! kga~l rssidenee aad domicile in the S4te ot Florida.
IF iOR THE PURPOSE OF ENROIL ING I F F'OR MONESTEAO PIfRPOSES~
~CNILOREN IN SCHOOL~ PIEASE STATE PLEASE CNECK: ~
TNEIR NANES:
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r I FURTH~R CERTIFY that I wt~! registtr at my local sddres~ when the registraiion books reopen, and comply wiLh all
other requirementa of a legal resident o[ this State.
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s~ I F~JRTHE3 ~RTIFY thst I have no intention to return to my [ormer domicile, and I intend Lo remain io
f~, //~/~L C S T. L U C I E _ County.
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` Florida. rmanenti
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(Addna~) -
Sworn to and subsc~ibed betore me thu ~ day o[
~ ' - A.D.19~.
R P01 +A ~ C~ERK OF C IRCUI T COU2T
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- ST. LUGIE COUNTY, FLORtUA % •
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BY: 300K~W f'AGf
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~ , `EPUTY LERK
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