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TO THE CLERK OF THE CDiCUIT COURT,
Si'. LUC 1 E COUNTY. FLORIDA; .
This is my declaration of Domia7e and Citizenship in the State of Florida that I am 8liag this day is socotdaaae, and is
conformity .vitb Section 222.17, Florida SLtntes, - -
I was lormerl a kgal resident o! 44 a S b is _ ~E N w d and I
. lGlty) 1StsW
resided at _ _ However, I have changed nq~ domic~e b
!Street and Number)
an_ d am aad have beta a bona Sde resident o! the S4te of Florida since daj d
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~ l9_.._L., and beside at ~CL ~~t ~r~ qv q
or r dRT~ (strr.taadNomb~xl
L Gs. G i l; S T. L UG I E County. Florida, I
tlst~l
and this statement is b be taken as my declaration of citisenship, actual legal residence and domicile in the State of Florida.
IF FOR THE PURPOSE OF ENROLLING IF FOR HOMESTEAD PURPO,ESa
CHILDREN IH SCHOOL; PLEASE STATE PLEASE CHECKL~
THEDIR HAMESt n -
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S~v~~ PR ITRYit j .
CCEI~ ClRCtNT COIIRt
- VERIFIEp .
I FURTHER CERTIFY that I will register at my locsl address when the registration books reopen, and comply with all
other requirements of a legal resident of this State. .
I FURTHER CERTIFY that I have no intention to return to my former domic~7e. and I intend to remain is
_ _ T. U C 1 E _ County.
_ (City) .
Flo; ida. permanent!;.
~AihLEc~r ~UoyC~
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tN.me)
30 of ~rtii~.ti. g ,otd~. .
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. vrn to and subscribed before the this ~ ° ~ .day of ~ • aC ,GGtt.tr t~ •~I?~ ' „3 ,3 ~T
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• ~~I t =~~x~e
.:OGER 17RAS. CLERK OF C 1 RCU 1 T COURT ~ ~t.
ST. LUG I E COUNTY, f LOR i OA Y :
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BOOK t7~~ PAaEz~~ _ '~'~;~c 3~ .