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TO THE CLERK OFTHE CIRCUIT COURT. ~
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ST. LUG 1 E opUxry, FLORIDA: - -
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Tbii i~'>nT declaration oI Do®iet~ and Cltiaenship is t§e State of ~7orida that I am filing this day in accordance. and is 4 ~
eoafotmii,T with Section 222.17. Florida Statutes. # ~ -
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I was fo~ a legal resident of y,?'~iCTy/G~ ` _ JU~Gt~ LT~7ZSE y and I I _
at 5 JT~E~T - Aonve~er. I have ehanaed doaaie~s ~ ~
1t3tr«it and Nombad - ~ , .
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and am and have been a bona Sde resident oI the State of 1.7orida sT~~e 1 ~710i ~ ; {
S~'PT~VI!l'B~ -19 and I reside at ' { .
lt3treataadNomb~rl ~ F
YVIZ7 ~ Ll)C/~ - ST. LUG I E
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and this stateme~ is to be taken as m~ declaration ~ citisenship. actual legal residence and domiea~e in the State d Florids.
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If FOR THE PURPOSE Of ENROLLING. If FOR HOMESTEAD PURPOSES, t
CHILDREN IN SCHOOL,-PIEASE STATE PLEASE CHECKS
THEIR NAMESS _
t
X979 SEP 26 PSI 2 13
- FILED ANO FECOR~1tU
ST. LUCIE COUttiY. FLA.
ROGER POITRAS~ ~ ~a
- - t2.ERK CIRCUIT Cti~~'~~"'
RECORD VER;FIEO_~ -
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I FURTHER CEATI>:'Y that I wiII register at m~ local address when the registration books reoptn. and eompl~ with sIl
other regmrements oI a legal resident oI this State.
I FURTHER CERTIFY tb:t I have no intention to return to m~ -former domict7e. and I intend to remain in
T. U C I E _ Connt~.
Floridi. permanend~.
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Sworn ~d 'bed befan me this daj o[ -
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• t A.D.19.
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R A C ERK Of CIRCUIT COURT - ~
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ST. 1 E COUNZY, f LOR t OA - -
BY: -
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EPUTY JERK ..~;i.•