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Q~~larati~~ of Q~m~c~le and ~stizenship ~
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TO TIIE C4FItK OF THB ARCUIT COUTtT. • ~
ST. l UC 1~ COUM`Y. FLARJDA: .
7T~i+ b m~ deelu~tioA ot Domicik ~nd Qtiteaship ia tbe State of Florida tlut I ua i~ ti?is dqr ia acoordaece. aad ia
-ao~toraaitr MrkA Seetiow ?22.17. }'lorida S ~tes.
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~ . 1 vras tormeri a k~al resideat ot ~ . ~ 1 .
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resided at _~i~_~ tsaat..d Ns~wr - Ho.rerer. I~are dua~:d ap domic~e eo
atid sm aad !?ave beea ~ bont ~ residcnt ot tbe State oI F7osida sinec dsy ot .
~ Ia~and I reside at ~ -
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' ST. lUG 1 E
taVt
and tlm statecneat is to be tskco as m~r detiaratioa ot eitiunship. actusl kp! rdideate iad daatie~e is tbe $tate ot Fbrida.
~ IP POR THE PURPOSE OP ENROL~iNG ~ IP fOR HONFSTEAD PYRPOSESy
'CIrIIOREN IH SCNOOL~ PlEASE STATE rLEASE CNECKS ~
- tHEt HAMESt
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• i~~o A~s~ ~ECOa E9 .
. . at. ~uci~ c~u~rir ~i~.
BCE~. F~~'~AS
. . 'CLE~iK C~~Cit1T COilRt ~
. ' RECt1F;; Y€RtF~Ep
. ~ OcT I I 3.26~ PM '75
• I FU7~TI)ER CERT7FY tAst I w~l register ai m~ bcal address wlrcn the registratim hool~s teopen, and cmapl~ ~vith ap
-otber requiremeats of a Icgai resident oi this Slau.
_rI~F.it~',~ t6:t 1 hare ao iatrniia~ to retorn to (ormer domieik, and I intend to renuiu in
___"'q~.i~J' Jl~'.A/ ~+.t~ ~T . l. U C 1 E Coubty.
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~ Y~ G~ Sworn to and subxril?ed betorc mc ihis dar oT
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~ } . . A.D. ~9 7.S
~ ROGER POI ASj CLCRK OF GIRCUI7 GOl~2T ~ _
• ST. lUG COUNTY, fIORiDA .
eY: ~..,Lc~e,. to`' ~
~ EPUTY LL'ItK
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irw 11 '.2
' BOOK~4~ PACE ~
44
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