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Dectaration of Domici~e and Citizenship ~
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TO THE CLERK OF THE CIACUIT COURT,
ST. lUC I E ~p~y. ~,p~p~:
• Thb b my deeluation ot Domlcite and Cit~en~Alp ta the State ot Florida tbat I uA GUna thi~ dy in ueordancs. and in
eoatoraaitr ~rith Seeeioa 22Z.17. Fbrida Statutes. ~
I wa !o~ a kgal re~idsat ot L?I~/ ~ K Td W~V ~ ~ ~Yf l~? T~ R-s ~ Y~d I
ICit7) (BtatN
rtafded at / O~ Rn~ S~ V E[. T D R _ Howevar. I bavs ehaaged mq domieile to
18tn~t ~ed Numbwl .
u~d an? and hav~ beea s bona fide resideat ot tbe State ot Florida siacs C~ T 3 dar o[
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-19~a sod I e~d~e at ~ S~~4 S Oe.1~s D R,:_ .
- - (BteMt ~d Nneb~tl
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N J~ N B E'/~ f1 ~ ST. LUC 1 E Connty. Fbrida.
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and tlw ~tatement is to be t~aken as m~r dee4ntloa ot dtiua+tdp. aetual kgal re~idenoe and domic~e in tAe State ot F'lorida.
IF fOR THE PURPOSE OF ENROIIING IF fOR MOMESTEAO PURPOSES~
CHILOREN IN SCH00~~ PLEASE STATE ?LEASE CHECK: ~
THEIR NAMESZ
• FN.fB aliD itE~pRDEO
~ u~E CO~Mrri f1A.
~l~~R~CWt WURT /
RECORD Yf~t~FlFC .
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I FUR1'~iER CEBTIFY that I wili ngister at my local addre.sa when the registration booica nopen. aad comptr writh all
other nquirements oE a legd re.sideat ot this State.
I FURTHEZ CERTTFY thit I have ao inteation to return to m~ tora~er domieik. and i intend to remaia in
:7~Ns !_=N f~ ~f4 c' H , ST . L u c ~ E , Councy,
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Fbrida. permsnentt; .
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Sworn to and subscn'bed before me this 3 day oi _~N s~/? ~~/4 ~'/7~ F< /~I •
, /1
r A.D.1917 ?j ~j y,~~
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ROGER ~OITRAS. CLER OF CIRCUIT COl~2T ~
ST. LIIC I E COUNTY, f LOR 10A • '
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EPUTY LERK • " Mr' ' ~
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' AGO Form 71 22