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TO T~Ir: CL~:RK t)1~' T!!E ClRCUIT COUR7'~
ST . L UC I~ COUN'fY, h I.ORIUA:
This ts my dcclar~lion o[ Domicile and Cilir~nship in the Stato of Flocida thet I am Ctling lhis day in sccordanco. snd in
eonformity with Section 222.17. Florida Slatutes. _
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I was torm~•r~ s Iega~l resident o! ~-~a . .N~'~ and I
. tCity) IStatai .
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residcd at y o o ~r ~s~ 5/,~,~ e~ _ Iiowevet. I have changed my domicile to
(Street aud Num~erl ~ •
snd sm and ha~ e beetl a bona fide resident of the Stete of FloridR since ~ 0* day of
a N~~-~ _ _.19..~~ and I reside at ~ 3~~ Oq~m o~• f G~c
T - lStreet ~od Nna~Dcrl
po,N~' ST Lvc. i t ~ S7. Ll1C 1 E County, Floride,
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and this statement is to be taken as my declaration ot citizenship. actual legal residence and domicilo in the State ot Floricta.
I~' fOR THE PURPpSE OF ENROIIING ~ IF FOR NOMES7EA0 PURPOSES~
CHIIDREN iH SCHOOL~ PLEASE STATE PLEASE CHECK: ~
THEtR NAMES: -
~G~N~'TeN ~.~/,V nr e t S"~ ~Tu ~t. ! S
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. F°~CO RECORDEO
! r~U`.;TY FLA.'
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'79 J;~'; 29 ~i 9: I s
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1 FURTIiER CERTIFY that I w~71 register at my locul.address when the registration baoks reopen. end comply witt~ atl
other requiremenis of a legal resident oi this State.
I FURTNI:~ CF:RTIF'Y that I h~ve no intention to retvrn to m lormer dnmicile. end I intend to remain in
uc ~ . U C 1 E . County.
ICityl .
Florida. permanen~i; . ~
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::i~'';? ' (Name)
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S~ to snd subscrihed bciore ~ne this ~ dny oi
, . A.~~. 79 ~ - ~ -
ROfER POIT S, CLERK OF GIRCUIT GOURT
ST. ~UG I E GOUNTY, f LOR 1 A ~
BY: ~
EPUTY LERK
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