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~3~~~~~~~~~~ Q~ ~~micQEe ~nd ~E~~z~~~~~ep
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TO T11E CI.I~:lli: OF'TlIE CIRCUIT COURT~
ST. I.UG 1 E cpvnrr~t. ~.or~ln~:
. This p tr:y detl.~ratao of 1)otnicile ~nd Citizenship in tbe State oI ~1orid~ that I atn Tilins this dq ia aavtdance, and in
tonformitr witt~ Section :.~.17. Fbrida St~tutcs.
I r+as tormr~ s lrgsl resident of ~ o/Q T~~?/Y~ ,~y ~oIQ ~ and I
(Ci~l Iblat~l
• midtd al yt~iCt T~~ ~F ~ n tt JQT _ jlowe~~es. I bave ehse~ed m~ domicile to
(Sue+t nd h.mberl ~
and ~m and have 6ee~ a tana Cde residcnt oI thc Statc of Fbrida since ~ day of
~G 1 19_ / ~ - o?d i reside at ~~~T~ J ~ ~'d
• lStroee a.d Nomhcr)
~i EIP G~ sT. LUG 1 E County. F7or;d..
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and this statemeat :s to be Wccn as my deetantion of citezeastip, adual legd residenee and domieile in the State of Florida.
IF FOR THE PURPOSE Of E~fROLLIHG If FOR HOMESTEAO PURPOSES~
. CHIL~REN !N SCHOOL~ PlEASE STATE Pl.EllSE GHECK: I--I
THEIR NANESI
,N1, s 5 ~c. s~/~,~i N.%~VTy.E1~? i~~~
/~?.RST~f2 ~AIQ~C ~'1 i /5~/1~ ~R FItED akJ ~t~C~ROEe
~ y ST. L~Ci~.CDUNTY FIA.
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0'I.s4 ~n~~~v H~,fs//YOC`.~4 c~EFx c+ :~u~j COURT
• aFr.n~:r v= ~.~,E^
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- I FUItTIIEit CF.1tTlf`Y that I~vill re~;ister at my local address when the teFi.ctration books reopen, and compy with all
olhcr rcqu~rements of a kga) re~ident oT ths State.
I FUIiTi Z C'FtT1PY ihr.t 1 havc ao intratiun to miurn to my former domicile, u~d 1 intcnd to rcmnin in
~~i t R G C , ST U C 1 E Couuty.
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Fiorida, pcrmanrnti~.
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, Stcorn ta and tiubstrl,nl l.clorc ~nc ihis _ day of i/'~ l~/Q G t ~ ?
~ C~ e.~~~-c't.~ ~ ~.n. ~a 7.5~
~ RnGC{2_I?OITRhS,
CLERK_Of GIRCUIT COICtT
~ sT, ~uc. ~ couwrY, r~orc~on .
DY : ~ ~'cti:.~~Z~ .
CYUTY LL"Ith
A f:0 F'.e n~ i 1:'S
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~o~ 244 p~ 2455 !
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