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Declaration of Domicile and ~itiz~nship
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TO THE CLEAK OF THE CIRCUIT COURT. a~~~'~ 13~ ~
ST. lUC 1 E Covt~r. ~'I.o~un~: ~
This is mr decl~ration ot DomiWe and Cit~seasfiip in the State ot Florida tbat I am tjl'~ng thL da~r ia accordance. ud in ~
oonformity with Section 271.17, Fbrida Statutes. -
I aa,+ f~~ s legal nsident ot Ti'~/8 U/~ C Q/~ aad I
IGt71 lBtaW
resided at ' ~T~ L~ LL.~ I~~ However. I have ebanged m~r domicile to
(8tre~t aed No~)
and am and h~ve beea a bona fide resident o[ the Stste oI Florida ainos da,p ot
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~ /7 . .19~. aad I reside at _ _ . 3 / /~D Ad ~/~/~S / .~IQ ~.i~'f~
~/~~PT S,T. ST~ t~c..aNmne~rl
~ J? c ~ E , L l!G I E Councr. Florida.
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and this statement ia to be takep as mr deelaratioa oi citiua~lup. adual legsl residenee and domicile in tAe Stste ot Florids. `
• If F'OR THE PURPOSE OF ENROLLING IF POR HOMES7EA0 PURPOSES~
CHIIDREN !N SCHOOI~ PLEASE STATE P~EASE CHECK: ~
TNEIR NAM~S2
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I FURTNER CERTIFY that I. will register at my local address when the registntioa books reopen, snd eomply with all
other requirements of a legal resident of this State.
I FU~ E~ CERTIFY that I rave no iatrntion to return to my form~r domicile. and I intend to remain in
F'O.P f c''~:' .C 1'~ ~l.F , S r. L u t ~ F . C«,Aty. ,
tCie~1 .
Ftorida, permanenti; .
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- Swynr~o and aubscs~ befure me Lhis day of _ _ ~D~Y ~ ~ ~ l ~ f'~L/~ •
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. . A.D.19 76
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~'~~~'~;Yrv~l ~AS,' CLERK OF C IRGUI T COURT ,
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~ sT. ~uc i~E~ couNr~r, F~oR i.on
BY: ~ Gv - /C~
- _ EPUTY LER p F }4~ S~.O
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