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Declaration of Domicile and Citizenship ~f ~
' SU9991
TO THE G'LERR OF THE CIRCtJ1T OOURT.
ST. LUG 1 E ~pUNTY. FI,Og~A;
This b nq declaratbn o[ Domicile and (xtiseoship b the State d IPlorida that I am SItaE this da,T is aooo~danoe, and is
ooniamitT with Saetioa 2.17. F7oiida 8tatntes.
resided at
I was i ram a Iega1 resident a[ ~j1~ ~' ~K to ~ERC N ~, / ~i~, Ci / u /A ~ I
_ teal t:~.w
Hawa~rer.I have ehanEed np domi~e to
" I~Nt asd leaf
and am and haw been abona Sde resident d the State d Florida ainoe /~, /~ - -- dq d
Tl Z,R C 2 ,1~~~. and 1 reside at .~ :i,T la~1 ~ I ~! 1.7 ~JQ ~ U ~ S ~
f?T - ~ ~ ~ (fie (F_ i~.rw..ti.r1 ~: Fbrida,
ST. LUCIE
c~cl
and this atatemeat is to be talcea as ap declaration d citisenship. aetnal heal sesideaoe and domicile in the Stator d ><7oeida.
" IF i0R THE lURPOSE OF ENROL<.IN6 IF FOR MOMESTEAO lt1RlOSES,
CHIIOREN IN SCHOOL, lt.EASE STATE !LEASE CHECK: ~`~,
THEIR NAMES: ~~l
1980 DEC I 0 AM If ~ 34
'~` st ii car ouintY`~ ~.
ROGER f'OITRAS
CLERK CIRCUft Cp~1
pFCODQ yrq~F r,.
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S(~91
I FtTI1THEii CF.IiTffY that I wi11 remoter at q bat addreaa when the r~itfsatioa boob reopaa, and eomp~ wits aD
other regniremems d a iesal reaideat d this State.
I FtJATHL~t CQtTIFY that I bne no intention to retora to faemer doa~De. and 1 hstend to remain in
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tacit -
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• 'iii before me this ~~ dq d Y -S~
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ROGER POI7RAS~ CLERK OF CIRCUIT COt~tT
ST. LUGIE COUNTY, FLOR1
- - BY:
ElUTY JERK
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