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D~clarafiion afi Qomicil~ and Ci~iz~nsf~ip
~ ~ s~.2z3s
TO THE CLERK OF THE CIRCUIT COURT.
ST. LUC I E Cp~Try. ~-I,pRIDA;
~~
This is my deelaration oi Domic~e and G~tiunship in t6e StaLe of Florida that I am Sling this da~ ia aocordance. and ia
conformit~ a~t6 Section ?22.17. Florida Statutes. ~
I R as formeri~ a legal resident of ~//E - /~ '-/ - and I
~ 1(tit~) (Stau)
resided at ~~~/~ ~' ~u--~' lv ~ - However. I have ehinged my domic~e to
(StroetaadN~ber) ~ -'
and am and have been s bona fide resident of the State of Florida ainee ~v~~ ~"~~ ~~ da~ at
/
.19 ,andIresidtat ~~ ~'~ /C~~/~' 1Q~~~/ ~i ~•
(3treet iDd Numberl
,.1~ /• s' ~- ~ vGt F"r- ~ ST. ll1G 1 E Count~. F7orids.
tae~)
and this statement is to be taken as my declaratioa of eitiunship. actual 1ega1 reaidence and domic~e in tbe Stat,e of Florida.
" IF FOR THE PURPOSE OP ENROLLING
CHIIDREN IN SCHOOL~ PLEASE STATE
THEIR NAMES:
.--
- .~
IF FOR HOHESTEA~ PURPOSES~ -
PLEASE CHECKS i/~
~r ~
~~ ~a~ -2 P;~ 2~ 43
F~LEC thC ~: COt~Di D
5 ROGER ~OITRAS~
CLERK CIRCU~i CC-liRi
F.i f,(W;1 Y4~a!F 1~ ^_ i.~/~~ --
~
512236
I FURT'~~R CERTiF'Y tbat I wU register at m~ local addre» vvhen the registration books reopen. and oompl~ ~vitb all
other reqt:irements of a legal resident of this State.
I FURTHER CERTIFY that I have no intcntion to return to mr tormer domieDe. and I intend to remain in
~~7` ~. . .~ ~. ~ i~ -- ST * L U C 1 E . Count~.
~ '~ ~ ~ _ IC'R~1 .
F'lorida. permanenu~. .
~~ COU,yr - ~~~
;`; ~~~~ ~, ,/ ~.~~' ~ ~~ ~
~: _}-~,~ :o i~ .~~ GY ~ /'TY~
_ C ~ _ ~ =.~i) '; G / j .
~: t~l~:;~;~ ~'c~ ~ ~r~ ~~ ''''/ GC~ /9~~% ~ I r~
~ ~~ r • ~ ... ~ ; : • J~~ ` ~--~ > ~~ /iE:~ .
.,~,~ _ .. 'r ~ ~ /~ ,~ G ~~' / ~
~.~.... _.~~~ ,
Sworn to and subsm'bed before me this ~ da~ at
~ ~.D. . / 9 8/
,
ROGER PO I TRAS, CLERK OF G IRCUI T COC~2T
ST. Ll1G i E COUNTY, FLOR 1 OA •
• +.
BY: .~ .
~~~ _ UEPUTY I.LERK
(Addr.af
~o~ IX ~ ~ o~
8~~3~5-p~~277'3
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