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'I'O THE CLERK OF THE CIRCUIT COURT.
S T. L tJG 1 E COVN'1'Y. Fi.ORIDA:
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This is my decl~ratioa oi Domic~e and Citizensl~ip in the State oi Florida that I am fi1Lng lhSs da~ in socordanoe, and io
coafof'irilt~ R7LL SeCt10D ~.17. Florida Statutes. -
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1 w~as lormeri~ a 1ega1 resident oi j'~1 • ~- ~~~l >> ~a I
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re s i d ed at ~!' ~~~~ ~ ~ c~~ Hoa ever. I bave ebanged ~ domicile to
IStmt aad Namba) •
E r d a m and bati e beea a boaa Lde resident ot tbe Stat,e oi F7orida sina 44' ~~~ ~!~Y' n~ da~ a[
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.19 ~d and I reside at ~~~ `~~ ~' ~ ~~~
) . ' ~ tStreet ~d Nambad
~"""t. t\~~. ~ ST. L UC ! E Count~, Florida.
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and this statement is to be taken as my deelaration of eitiunship. aetual )egal residence and domic7e in tbe State of Florida,
- lF FOR 7HE PURPOSE~OF ENROLLING
CHIL~R~N IN SCHOOI~ Pl.EASE STATE
TNEIR NAMES:
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1 FIJRTI~R CERT'IF'Y tbat I~71 register at m~ local address when the registration books reopen. and oompl~ svitb aD
c:~er requiremenb of a legal resident oi this Sttte. _
I FURTHER G'ER1'IF'Y that I have no intcntion to return to m~ former domieile. and I intend to remain ~n
"" ~ J T* L U C 1 E , Count~.
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I F FOR HOHESTEAD- PURPOSES~ ~-
PLEASE CHECKt ~
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ROGER POITRAS* CLERK OF CIRGUIT COC~~T
TeQeSA l~en~ yoN ,~
ST. LUG 1 E GOUN7Y, FLOR 1 OA •
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(~~ ~EPUTY LLERK
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