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TU7'1lE CI.F:ItK OFTHE CUtCU1T COUltT,
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ST_Ll3i, i E coutwrY, t'i.viciiin: ~
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This is my d~claration of i)omicilc and Citiunship ia th~ Siate o[ Florida ths! I am filing this day in sccordancc. s?nd in `
contormily with Scctiun 222.17. F lorida St~Wtcs.
I was !or= m~rlx a legs) resident ut ~M~ , _ ~?nd 1
1(.Yty) lst.te)
nsided at l.~, . llowover~ 1 h~?ve ch~nged my domicile to
1~~ ~+d Nuwbcr) ~
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and am nnd l~nvo t?cen a bona Gdo rrsidrnt ot thQ Statc o! Fbrida sir~co day oi
''~1 8-~-`e•^-~`~~ .19
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- and I reside at ~ ~ S:2 ~ ij ~ -
~ ~ (Stroet snd Numbec)
~ ST . LUC I C Counly, Florida,
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and this slatem~nt is to be t~ken aa my deelaration ot citizensfiip, actual lega! resideaec and domicile in the Stato of Flarida.
I i' FOR TNQ PURPOSE Of' tNROi.I ING . I ~ FOR HONESTEAt1 pURPOSES~
CHII.DREN tN SCHOOI.~ Pl,EASf. S7ATE. PLEASE CFIECK:
TNEIR NANES:
- ~:t.=0 ;.t1~ ri~COROED -
' ' .-''"'r' %•ril"TY, F y
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I FURTIiF.R CERTIFY t1?at I wilt register st my loca! address wt~en the mgistration baoks nopen. and comply with ull
other requiremrnts o[ a Irgal resident oi this State. ~
1 FURT}iEZ CF.RTIFY thr.t I have r+a intc•nLion to reiurn to mv formcr do:nicile. ~?nd I intend to rcr~nain in
, U G 1 E . C~unty.
ICittl .
Florida, pcrmancmi;.
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o~ (N.me) ~y .
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A` ~~CUNTY. . - ~
~7p01e~~?`~• r (Addros~)
Sw orn lo i:n~i sut?scribr~l beiv: e me thu dap of ~
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F;OGCR PO! TRAS, CLERK OF C IRCUI T GOl~2T
ST . 1_ UG i E GOUNTY, F t_Ok i t~A ~
BY.
~EPUTY C~LE~:K Cr~s2~~ I
E J~.. s'.
1t;ft i'+,: r., i 1'.
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