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Declaration of Domicile and Citizenship
4 ~19l~1
TO THE CLERPC OF THE CIItCtJ1T OOURT. .
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ST. LUC 1 E COV~q~ FI,O~p;
Thb b mT dselaration d Domiefle and ptbsoshtp fa the 8taa d Florida that I am ~g thb dq b aoeoedana, and In
conformitp with Section 272.1T. Florida Statatas. i
I was for ~e s Isgal reddest d Ct _l ~11?t~it/7)'C~ _ ~ ~ Cn 1U l~ and I
(a7~ 1et+R.a
resided u /9g3 [ l ~ l')'119/ ~ ST - Haweve~s. i haw changed mT doaoieile to
18trNt of N~MN
. and am and haw been a bona fide resided d the State d Florida dace ~/q ~C~ 3/ ~ - - - ~dq d
~ .19_.~C~. and I reside at 3 / 7 SLU ~/lam ~'~~.eT' l~~
(BnMc ssi NowMrl -
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and thb statement b to be taken as nqT declaration d dtisenship. adnal legal residence and domkile is the State d Florida.
_ ~ If FOR THE PURPOSE Oi ENROLLING IF i0R NOMESTEAO PURPOSE8,
CN 1 t.DREN i N SCMOOt., Pt•EASE STATE PLEASE CHECKS
~ THEIR NANESt
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I FURTHER CERTIFY that I will at mT k?al adde~sss when the registration boob reopen. and aoaopy with a0
other requirements d a legal resids~ d this State.
I FURTHER CERTIFY the I haw m intention to return to m~ focmer___ damiei and I intend to remab io
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Florida. permaaenci,•.
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Swoen to and anbeeribed before me thb ~ daT d ~ ST ~L/C'/~ . C=l. ~~SZ
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A.D.19 V
ROGER POITRAS, CLERK OF CIRCUI T COtd?ZT
ST. LUG 1 E COUNTY, fLOR 1 OA
eY:
EPUTY LERK
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