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TQ ~IIE STA1E ANO OOUPIiY TAX A5S6~QR.
Thb is my daclaratkm of,Domldl~_ and CiMarna111q ill the! ~Shle ~f. flOrid~ thM~1 stn fNMQ Cilia dh- M aooordMloa and
In conformity wNh Chapter ?~4. Seetlon S~t17~ ~'~_~ .
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1 wa formerly a legd resident of-----~- ~~NttiQ~-: .._~..__ ~.=, -`--.~R~.,~.1~~----
end 1 resided et ---32-.~Q~- --._____._~-.~.~---- --~_ 11owwK. 1 have dlarged my ~~idle
to and am and haw been a bona fide resident of 1M-StaM of_telorWa alnae__r:.~__r~:. ~ ,_ day of
---~La>s~~~ ----- ~ . ~9~]....rKt 1 n.w. at _~lQ~t~Ltlt~Pris~t.-Yi.~Li.Blvd.
--- ----------------T.at't- ~ ~ $t_ iuei County, porlda,
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and this statement is b be taken as my declaration of dNeergilip, ,ttual legal reaWerloe std domkile in the State of Florida.
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aswd d icy a wcw donirJfsi, ~ueetw. d ~ MeJ .
Establish Residency
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ROGER POUN~YSf1A
St, lUC1E 6 ~
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I FURTHER CERTIFY that i will register at my local address when the registration books reopen, and comply with all
other requirements of a legal resident of thin State.
I FURTHER CERTIFY that 1 have no intention to return to my fom~er domidle, and 1 intend to remain in
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--- -- --~~IE-~~e --------------=------ -----$t.-Lucia ------------------ ~+n Florida
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v ; 4 r.- 1 ;,~. Ben~aitiin R. Russell
'~ ~ ~ibsd before me this_ _fLth _~,y ~ J~?~?-a?~ ______________, 1962
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• ~ ROGER POITRAS, CLERK CIRCUIjfOURt ~dY Pubiic
BY ------- ~~~ r~~'~•--- ~~'~---- ~~• MY Commission exPi~---- -----------------
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