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TO T!!E CGERK OF TItE C[RCU1T COUAT. '
SY. LUC 1 E CpVrJ7'y~ FLORIDA: '
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'Z'hb b my deelaration of Domieile and Cit~cnaAip in the St~t~ ot Fbrida that I arn C~lfng this dar ic~ accocd~nc~, ~nd in ;
coafo~mitr with Scttion ~.1T. Florid~ Slatute~. ;
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I a?a t~rm~rl a kgal ccaident ot F`~~-~ ~ ~ ,OQ , ted I
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~e~tded at 3Q~ ~ - Ho~ever. t Rav~ ehangcd tnr domicile to
tSw~t and Nume.•1 ~
tad am ind have Deea a bona Cde resident ot the State ot Florida ~inn dar ot
~ v~` 19 ~ ~ ' aad I re~ide at SO . ~ ~
` (StrNt ~nd NumD~~l
. ( ~L ~ ST . L UC 1 E Couatr. Florida.
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and t2~is atatement is to be taken u tny declacatioa oI cit~zeo~hip. aetual kgsl rc~idence and docnicile in the Ststo o~ Fiorida.
Ii fOR THE PURPOSE Of.ENROILING• Ii FOR HONESTEAG PURPOSES~
CHILDREN IN SCHOOL~ PIEASE STATE PLEASE tHECK: ~
THEIR NAMES:
\~~',c-.v, L ti . ~
~c~ . ~~~~uci~'~ouN~r ~k'i~
} O~ ~ ~ OCER P4!ZR~S
, r! e~•'K r.;RCUfT C~ r*
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A°A 11 II 42 Ay ~1Q
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I FURTEIER CERTIFY that I w~l registcr at my local address when the registrstion buok~ reopcn. and comply with all
other requiremc~t~ ot a icgal resident oi this State. ~ "
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~ I FjJRTfiE:t CERT Y tA~t I have no intention to return to my former domicile. and I intcnd to remain in
~ ~~4. C Sc_. S T. L U C 1 E _ - _ County.
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~ Florida, pcrmanenti~ .
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' Sworn to snJ subscrit,cd bcto~o mo thi~ day o( Q,~ -
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. A.n.19
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~ ROGER POIZF2nS. CLER{C OF C IRGUIT COUF2T
~ ST. LUG i E COUNTY, F LOft t.UA ~ ~
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AG(1 F'orm 11 M
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