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TO TIIE C[.~:l~It 0!' TtIF: CtRCUIT C.OU1tT. ~
ST. LUC i E COUN'TY. I~'I.ORIDA: ,r
This is my declaration af Domicilo and Citizenship in tho Sta~ta of F}orids lhnt I sm li~ing this day i~ accordnnco. snd tn
contormity with Scction 222.17. Florids Statutea:
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~ wns tormcrl a legal resident ot ~ ~~~tr~ ' ~st.te) :
~ . liowover. l hnvc chsn~ed my domicilc to ~
resided at ~ # ~ ;
(3trest aud Nua~Mrl '
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and sm and have been a bona Cda resident of the State oi Floridn since l' p`~ - r
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19.1.1t_. and I reside at lg~ ~ Number)
- ~ D~~,`~ ST . l. UG 1 E County. Florida.
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and ihis statement is to be l.alcen as my deciaration ot citiunship. arlual legal re~idcnee and domicil~ in the S/xte of Florida. ;
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I F FOR THE PURPOSE OF ENROLL ING I F fOR NOMES-TE/1D PURPOSES~ ~
PLEASE CIIECK: ~ ~
CNILDREN Ih SCHOOI~ P4EASE STATE ~
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THEIR NAMESi ~
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` I FURTIIER CERTIFY that I will re~ister at my local address when the registration books reopen, and comp)y with alt
i other requirements of a legal resident of this Sttte.
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I FURT}iF.~. CFRTIFY that I have no intention to return to mv former domicile, and I inl.end to remain ~n
~ T U C I E . County.
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Florida, pcrmanenti; .
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~ S~corn to and qubscribcd bcforo mc this ~ d~y of ~i -
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ROGER P01 CLERK OF CIRCUIT ~OU~T
ST L UC 1 E COUNTY, F L(hZ 1 vA ~
BY: j~ ~
CPUTY I.ERK ~
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