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'FD THE CLERK OF THE CIRCUIT COURT. ~t"~~S
S'f . L UC 1 E COUNTY. FLORIDA;
This is my declaration of Dotnieile and Citizenship in the State of Florida that I aai filing this day in aocordanoe. and in
_ coaformit~ .vit6 Section 222.17. Florida SLtutes.
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I rru former pa~le~' resident of _ d I
resided a! However. I have changed my domicile to
(Street and Number)
and' am anal have been a bona fide resident o! the State of Florida since ~ day of
y ~ -19~, and I wide at r~ `
-~(3~aod Nambed
ST. LUG 1 E County. F7or;da.
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and this statement is to be taken es my declaration of citizenship. actual Icgal residence and domicile in the State of Florida.
IF FOR THE PURPOSE OF ENROl.t.1NG I.~.~ FOR HONEST.EAD PURPOSES, i
CHII.OREN-IN SCHOOt., PLEASE STATE PCE~AS~L~' CHECK:
THEIR NAMES: ~ ;
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45~688 ,
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I FURTHER CERTIl~'Y that I will register at my local address when the registration books reopen. and comply with all
other requirements of a legal resident of this State.
I FURTHER CERTIFY tha I have DO ' teation to return to m~ former domic~7e. and I intend to remain in
7. U C 1 E .County.
(C.it~)
f•'torida, permanenti~: _ ,
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` IAaa~e.
Sw ora to and sub_,rnZ+ed before me this ~ day o! ~ O
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ROGER POITR CLERK F CIRCUIT COURT -
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ST LUGIE COUNTY, Ft02 DA
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' EPUTY~LERK IlB
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