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TO THF CI.I.RK OF THE (:I1tCUIT COl1R.T.
ST . L lJC I E COUNT~', F'I.ORIDA:
This is my declaralion ot Domicile and Citi:.enship in the State of Florida that I am filing this day in accordance, snd in
conformity with Section ~12.17. Florida StRtutes.
I was torm~rl a legal resident ot ~ l~ L and I
~ ' ' ~ ~ ICityl IState)
resided at ~ . However. I have changed rny domicile to
. (Stteet and Numberl
and am and ha~ c becn a bo;?a fidc residcnt ot the Slate ot Florida since ~T_ day of
/ C` ~ . ~L~~
, l9 . and I reside at ~
• (Street aad I~uraDer)
, ST . LUC I E County. Florida.
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and this slatement is to be taken ns my declaration oi cititcnship. actuul legal rrsidcnce and domicile in the State af Florida.
IF F'OR THE PURPOSE OF ENROLIING IF ~OR HOFIESTEAO PURPOSES~
CHIIDREN IN SCHOOI~ PIEASE STATE PLEASE CHEGK; ~
THE IR t~AMES:
1/~Q ~~,c~
G_ ~ ` ~
. ~
r ~ 1~~'G n
lT~lIiC1E COUNT~ `lR.
RoceR Po+s~.s
C: EAK.C6R~UIT 1~
~ :=~'.Ii~T~ ~
~ - M~r 3 2 s3 PH'1~`~~
4~2~0'74
I FUKTIik:R CERTIFY thz! I will rey,ister at my local address whe~ the rcgi~tration books reopen. and comply with nll
; other requirements o! a legal residc~it ot thic State.
~
~
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r I FURT} '2 CE TIFl' iZt I ave no i~tcnlion to mturr to my formcr dor.iicile, and 1 ir,tend to remain in
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~ I~'lorida, permanrnti; .
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Sw•orn to and .ub~eribcd betnr.• n~e this dsy o( __,T, C',~' ~
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