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TOTHF CLEItKI)E 7liEC1ItCUlTCOURT.
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~ ST L l~C 1 E Cpt1NTY. F ~.oistna:
This m~• declaration of Domicile ~nd Citir.en!~hip in the State ot Fbrids that I em tiling tt~Is day i~ accordsnce, a~id in •
~onformity with Scction 2'~2.17. }'lurida Stt?tutcs. ~
I v?as tormcrly a Icgal residcnt ot ~ij t~ k i~~ t A~ , ~fl ~d ~nd I
/ (Cityl (Statd
~ccidcd al b'~~~ f~'~L+ ~•r o~ e~7~ . I;owevor. I havo ehanged my dumieile to
(Strsel and Alumber)
srtd nm and have bcen ~ bonu fido rrsidcnt ot the State o( Floride since C' ~ ' day of ~
'u .19~. and I residu st ~ ~ G S N ~Yf ~ . ~
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~ (Str~eet ~ad hutnber) • ~
~ T 11 ~ ST . L UC I E Couaty. Florida.
lCit~l
and this statement is to be taken ns my decleration of citizenship, ~ctual I~gRI nsider.ce and domicile in the State of Florida.
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IF FOR TNE PURPOSE OF ENROLLING IF FOR NOMESTEA~ PURPOSES~
CNILOREN IN S.CHOOL~ PIEASE STATE p~EASE CHECK: ~
7NE IR t1AMES:
(
NoY ~ 12 0~ PN'78 `
' F~tED ANU RECOROEO
St.~tIC~E COUNTI?.F~A, .
pOCER PQ)TA/~S =
ClE11K CIRCUtT COUR
_ RECORQ vER~F1E0 I~~~ +
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I FLIRTttt;R CF,R'F`IFY that I wil} re~isier at !«a1 addre~s w•hrn the regisiration bonks rcwpen. and comply with al! ~
oiher requirem~•n!c o.[ a lega) msident of thi~ 5tatc. ~
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I FURTHE:t GF:RTIFY th~t 1 havc no intrntiun to r~tur~
t=~n
m~ {orn:rr
d~rrii_`c:le, and I intend to r~m~in in z
~c-~-~.._ ~.IC~crl . t' . T _U C t E ~ . C~unty. ;
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