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CJeciaraiion C~omiciie and Liicizenship
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S~. LUG 1 E (~OUN'I'Y. FLOI;tIDA: ,
' ~ `;This is m~ declaration o[ Domicile aad CitisensLip in the State oI Fbrida that I am Bilins this daj is aooordaaos. and in
_ oonformly with Section 222.17. Fbrida Statutes.
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I was forme a kEal sesident of L~ - ~ and I
~ il~t~l IStalel
resided at ~~--9 --S - ~ ~ - Aoweres. I Lars cDanaed m~ domies~e to -
18hst aaa Nnmberl S}
an_ d am and Lave been a bona fide resident of the State at Florida since _ ~ 4 ~ 1 ~ daT d ~
.19 - and I reside at ~ ~ ~ s ~ -
. - 18a+~t asd Namb.el
Ski ~...i_t~ ~ ST. LUG 1 E County. Florida.
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andthis statement is to be taken as m~ declaration of eitisenship, actual kgal residence and domiale in the S4te of Florida.
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IF iOR THE PURPOSE OF ENROLLING If FOR NONESTEA~ PURPOSES,
CHILDREN IN SCHOOL, PLEASE STATE PLEASE CNE~K:
THEIR NAMES:
' r/1 ~ ~~~wrsQ~ y
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1/ ' _ _ ~ ~ ~'~ti,~oL X919 At~~ ~ 6 !~l ~ 35
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9~IZ'Q4 .
I FURTI~R CERTIFY that I w~71 register at m~ local address when the registration books reopen. and aompl~ with aII
other regnirements of a kgal resident os this State.
I FURTAER CERTIFY that . I lure no intention to return to mT former - domic9e. and I intend b remain in
• JT . L U C I E _ Count;
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Florida. permaaend;.
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Sworn to and snbs~'bed before me this daT of ~ ~-L _ ~ 3 ~~5~
R
M - ~ A.B.19_ _ -
R CLERK OF CIRCUIT COURT ,
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ST. L 1 E COUNTY, FL.OR 1 O - -
EPUTY LERK
. _ s~~K314 P~E20`~6
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