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TO TNE CLERK OF THE CIRCUIT COUR~
ST. L UC I E CQUN'ry~ F'L,pRIDA:
• This ls my declacation oI Domicile and Citizenship in the State ot Florida thet I am filing this day in accorda~ce. ~nd in
contormitr with Section 2~.17~ Florida 5tatutes. .
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I rras form~r{ a legal n~ident ot ~~A D i S fi /i/ v~/ ~ and I ~
lCtty) Istauf
resided at G v f' - Ho~revet. I have changed enr domicile to !
~Stn~t ~ud NumD~r) '
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and am an have bcen a boaa tde re~ident ot the State ot Fiorida aince ~ day of
19_~ and I reside at ii}'C J_
(Str«t aad Namber)
c e(~ C-' ' ST . L UC 1 E, ~ County. Florida.
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snd thi~ statcment is to be taken a~ my declaration ot citizea~hip, actual legal re~idence and domicile in the 5tate ol Florida. •
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IF FOR THE PURPOSE OP ENROLLING Ii' fOR HONESTEAO PURPOS S~
CHIIOREN IN SCNOOL~ PLEASE STATE PLEASE CFIECK; `
TNE1R NAHE5: _ ' ~ _
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' I FiTRTHER CEP.TIFY that I a~l register at m~ local addreu when the registntion boola reopeo. and comply ~vith all
~ other requirement~ of a icgal resident of this State.
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~ I FIJRTHE;t CERTIFY that I have no intrntion to return to my former domicile. and I iatend to remain in •
~ • ST . L U C f E . County.
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~ Florida. permanenci~ .
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~ Sworn to and subscribed bctoro me this day of
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_ ~ ~-C~?' _ - . A.D. 19~ FILEO AMp HECUROEC'
- ST. ~t~~~E COUyTr ftR.
- ROG~R P41 T?2~S CLERK OF C IRCUI T COt~2T RocE4 F~itaas
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S7. Ll1G 1 E COUNTY, F ~OR 1 UA • ~ t n~ .
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