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TO TIIE CGERK OF TtiE C[RCUIT COURT.
ST. l UC 1 E
- -COUNTY. FLORIDA. ~
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'1'!tb b tnr dalantion ot Domle~le and Citiun~hip in the Stat~ oI Florid~ th~t I~m CUna thb d~y in aaord~acs. and (n
so~fortnitr witA Section ~.17. Florida Slatute~.
. ~ t3~9`J'h'I NG IP~G.~~' /1~~-w ~rdt ~ ,
I~rt~a tanr~~rl • legal resident ot
~t lCKrl . l~tat~)
cea~dcd at - ~ T~ ~(,(~T~~N ~1}' - However. I have ehanged rnr domicile to
t~tn~t wd N~mO~~? -
tad un aad have ~en ~ 6oaa fide reaident ot tAe State o~ Fiorid~ ~iacs ~ T.2 ~ d.r ~
24~. aad I ra~tde at ~Z`J 0 K~-f
IStn~t and Numee~l
~ ST. lUG 1 E Co~acy, ~ta~a.,
~cu,~
u~d tAis statemeat is to be taken a~ my dectsration o[ eitizenahip, actuai kgal re~idenee and domieile in ths Stato ot Florida.
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Ii fOR THE PURPOSE Of ENROLLtNC If ~OR HOHESTEAO PURPOSES~
CHl~OREN !N SCNOOI~ P~EASE STATE PLEASE CHECK: ~
tHEtR NANES.
~ i.EO AIiO R CORpEO ~
LItC1E CO~MTr f1A.
_ ROCER POITq~ts
ri£RK CIRCU1t.C0UR
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_ ~ APR I~I 3 24 ~
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I FURTNER CERTIFY that I Kil! registcr at my iceal addres~ when the rcgistratioa t?ook~ reopcn. a~d comply with ~11
othec requirements o[ a Iega! tesident o[ this State. •
I FL1RT}IEZ CERTIFY that I have no intention to return to my formec domicile. and I intcnd to remain i~
' _$T . L U C t E ~ Countp.
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Florida, pcrmanenti; . ~
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Sworn to and subscrit,ed foro mo thia day oi ~~jGK ~.~'~C/~i~ ,7,3~~~`
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~ . A.D.19 ~
ROGER P01 TftAS. CLERK OF C iRCU17 COUF2T
St. L UC I E COUNTY, F LOR 1 UA ~ '
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rru~Y LERK ,
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