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'};O THE CLERK OF THE CIRCUIT COURT.
S~. LUC I E cacrr~t, FI.oRmA:
~ This is my declaration of Domic~7e and Citizenship in the State of Florida that I am filing this day is accordaact, and in
conformity with Secf.ion 2?2.I7. Florida Statutes.
' I was formerly a legal resident of ~ ~ ~~,t~t<_.1~? and I
. Itl't~) (State)
resided at However. I have changed my domicile to
(Street and Numbes) `
snd am and have been a bona fide resident of the State of Florida since , ~
7 day of
~~'~A--U~--C/`L 19~ and I reside at _1~~~
(9tr.~et dNnmiw)
~it_il/ ~~,LC„~~/ ~ _ ST. LUG 1 E County. Florida,
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and this statement is Lo be taken as my declaration of citizenship, artua) legal residence and domicile in the State of Florida.
IF FOR THE PURPOSE OF ENROLLING IF FOR HOMESTEAD PURPOSES,
CHILDREN IN SCHOOL, PLEASE STATE PLEASE CHECK:
THEIR NAHES:
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rer-r~xr-~
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I FURTHER CERTIFY that I wt11 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 CER'TIF'Y that I have no intenlion to return to my former domiu~e, and I intend Lo remain in
T, L U C I E County,
(Crty) _
Florida, permanenti,:
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, y
C~~i; . _
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sworn to and snb /Jfore me this day of
~%tq?t-~'ivt ~f,~.k~r~ , A_D.19
~ - ~ :^`~~C. - •
ROGER POITRAS. CLERK OF G IRCUt T COURT ~c ~_T ~T ~ F-~
ST. LUG I E COUNTY, FLOR 1 DA ~ 3 ~
BY: ~ •
' DEPUTY LERK ,
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