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TO THE CLERK OF THE CIItCU1T COURT.
ST. lUC ! E - opvrrrst. FLORIDA: -
Thislis'tog declsration d Dome and Cidsenship in the State d Florida that I am Sling this daT is sooordanoe. and ~
. oonformit,~ witb Section 22Z.1T. Florida Statutes. •
V /I,,
I was i~ a legal resident alT ~~~/~-~1
• _ ~ and I
X30 9 ~ .~Z
resided at - However. I have changed aqT dame to
ISt:.~t sad Namb~rl - -
and amsod bsvebeen abonafideresident tithe State d Florida since ~7 d
19!
~ - and I reside at ~ ~_J
_ = t aa~
u~ _ ST. LUG 1 E ~ ~ti.
~dbl
and this statement is to be taken as mT declaration d citizenship. actual legal residence and domieDe in the State of Florid:.
IF FOR THE PURPOSE OP ENROLLING - ~ if FOR HOMESTEAD PURPOSES,
CHILDREN IN SCHOOL, PLEASE STATE PLEASE CHECKt
THEIR NANES•
-t
- v ~ 1919 SAP 28 Pk 2~ 03 _
FILEDA~~NO RECUKpEU
Gel ~ sRLO~CaERPOITRASA
CLERK CIRCWT CO T~~ •
RECORD ~'ERIFtEO_-~
~L1V I ~V -
i - -
I F[TRT~IER (~RTIi''Y that I w~71 register at mT local sddreas when the registration boob reopen. and oomplT with aU
other regninments d a legal resided ad this State. '
I FURTHER that I ve .no 'tendon to return to m7 former domiede. and I intend to remain in
T. U C I E _ Count.
IC~tr) -
Florida. permsnenti;.
_ _
. - • -
- - / -
.
:j, :,~,y~ ~ . ill;,' 01 ` Q.
Swgtt'n -and ~ ~ ~ ore me this daT d ~ .
R • A C ERK OF CIRCUIT COURT
ST. LUGIE COUNTY, ELORtOA _
• . i~..~.: -
BY:
_ _
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.