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~ ~ ~eclaration of Domicile and ~itizenshi ~
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ST. LUC 1 E _ ~,p~~: ~
~This b~r ~elaratio+~ or poa~icjle ud Citi~aship in tbe Stats o[ Ffoeida tbat I a~ Qlio~ this dy? ln ucordaooe. aa~ in
eoetoeaajty wtth seeeion 22z.1T. ~'forid. scatuc... ~
I wsr f ine a ieasj resident ot ~~t'~ ~~u aad I
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»sidad at ~ o d~ S~ r~ S W_ _ _ Howswr. I lu~w ei~an=ed m,p domiale to -
t~Mt ~i N~OKi -
asd am aad l~aw besn s bau tZd~ resid~nt d tM 8tat~ ot t'loeids sino~ ~ ~ dap ol .
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aad tbis stacemeot ia to b~ tak.n as mp ded:ratia~n ot dti~ensAip. .ecasi kgal rssideaas aad domia'3e ia tb. Stace at ~'~oeida.
If fOR THE 'URPOSE OP ENROILiNG ' IF POk NOME3TEAD PURPOSES~ ~
CHIIOREN IN SCHOOL~ PLEA$E~STATE rLEJ?SE CHECK: ~
- TMEIR NANES: -
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. FIIED AMO RECOROEO
SL WC1E COUNTY FU.
AOGEA POITRIS
C,`~K C~9CU?T CO T
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I F'[JRTHE~i CERTIFIf tl~at I ~r~i ngister at m~ ioca! address ~rhen tl~e registntion booics reope~b: and eomply ~iith aU
otber requirements ot i&gal resideat of tb~s State. - ~
I ~CERTIFY tbit I have no intcntioa to retnru to my foiv~er domiea~e, aod I eatend Lo nmain Ia
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Sworn to and subscribed before me thi~ y day. ot /7
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_T_ . A.D.19. ~ 8 •
ROGER P01 TRAS, CLERK OF C IRCUI T COU2T
ST. LUCIE COUNTY, FLORIUA
BY: •
EPtlTY tERK R 9QQ ~`t C~~~
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~ AGU Fonn 91 22