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7'U TIlF: CL1:Ith OFTHF. G1IcGt11T C0U1iT, ~~~92 ~
ST. Ll1C 1 E Cout~rr~•, FLOKIUA:
Thi~ is my drelaratiua o( I)ou~icitc YnJ Citir.enship in lhe 5talo oi F lurida lhal I am fiGog this day in aec~rdnnce. and in
conformily H•ilh Seclion':12.1?. Florida_Statutcs. ~
76 ~~~~'~'~'`e ~ i
I wes torm~rl a{eRsl resident o IState)
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msided al '"1. Nowever. I have changed my domicile to
(Strest aed 1~IwuDaY1 ~
and am and ha~•e beee a bona Gde re'sidrnt of lhe State ot Florida ainee day o[
~dr 19..j~ . aod 1 resido at "`'"~~--P
~ (Strest and Number)
, ST . LUG I E ~ County. F~o~a~. ~
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and this stat~ment is to be taken as my deduation oi eitizensh~F. uctual legal residence and domicile in tbe Statc of Florida. '
IF FOR THE PURPOSE OF' ENROLIING IF FOR HOMESTE/1~ PURPOSES~
CHILDREN IN SCHOOI~ PLEASE STATE PLEASE CHECKI ~
THE1R HAMES_:
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i I FURT}iFR CERTIF'Y that I will register sl my local address when the regist~+clion books reapen, and comRly with all
~ other require~ents uf a Iega! resideai ot this State.
~ I FUIiTHi~::~ CERTIFY that T have no intention b return to i~v tormer domicile. and I intend to mmain in
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~ Florida. permanenti; .
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~ ~w•orn to nnd 5ut~~cril~d txdorc me lhis day of ~
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~ ,ER P01 TRAS LERK OF C Ii:CUI T COtI2T
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~ ST. ~ I~ COUNTY, f L~21 UA ~ -
~ BY: ~
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EPUTY LERr:
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