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. TO T~IE CI.ERK OF THE C1RCUIT COUIiT. • . •
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• ST. LUC 1 E COVNZ'Y. FLORIDA:
• Thu b mr declaration o( Dom+cilc and Citiscn~hip ia the State ot Fto~ida tl?~t I am C~lia` this day ia aceordance. and in _
conformitr with Section 222.17. Fbrida Statute~. ~
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I ~?as torm~r~ a lcgsl resideat ot I~r1 Istac•1 ,
. Nowever. I have changed my domicile to ~
rrsided at ,rL S ~ ~~/P
lStr~~t aad NumDe?) ~
-s _ day ot
and am a~d have been a bona C~de resident oi the State of Florida ainee `
~ 19...ZZ. and I reside at ! 2 3 3 -S ~ f}~[= ~ L~,~ 1 U~ : ~
~str.et.oa K~e.rt
~j 7 ~ U C ~ C~ ~ L.~ _ ST . L UG I E County. F1o~da.
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and this statement is to be takee u my declaration o[ citizen'ship. aetual legal residence ~nd domicile in the State ot Florida.
If fOR HOHESTEAO PURPOSES~
Ii fOR ir'HE PUR~OSE OF ENROll1NG p~EASE CHECK: ~
CHILOREN IN SGNOOL~ P~E~SE STATE
TNEIR NAMES: -
s~1i`f'S ~0 ~ECirROf L
50Cf
p~{t~!' rlJ~
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i I FURT~iER CF.RTIFY that I Kill register at my local addres~ when the registration books reopen, and comply with ~?ll
~ othcr requircmenis of a Iegal residenl~oi this State.
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; ~ I FUR IG:t CE:RTIFY that I havc no intrntion to retur~ to my lormer doinicile. and I intend to re~unt~n
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~ Florida, permanenti; . .
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R~GER F'011~2/~S,~Cl=i_Ri4 UF~ C IRCUI T CODU2T .
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ST. LUCIE CCUNTY, FlO;t1UA
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' 60014 ~a7V PAGE
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