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'1'4b a in~? aeel.ratios ot non~kil..na Cici~a~htp ia u» staa ot Ftioda. tiu~c I.ua titi~ u~is ay? ta .~ooc~a.ac., .aa ~n
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P~l~e ~ sT. tUC 1 _ Couacr: ~torida.
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" aa~f th4 st~tsenent b to be takea as a~ deel~ntfo~ o[ citaet~l~ip. aetual ie~t e+eatdeaae :od doaTkile ~a t6e 8tata ot Flortda.
IP fOR THE ~URPOSE Oi ENRO~~tNQ Ii iOR NOMESTEA~ PURPOSESi
CNI~OREN IN SCHOOL~ PI.EASE STATE ~ ~~EASE CHECK= ~
tNE1R NAMES; - . _
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CLERK CtRG T COURt
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I~1~ CERTIFY thst I~l register at my local sddrass ~r6ea tbe ngistration books ieopea. aAd oomply ~th all
oth~t requininents oI a lega! resideat ot this State. ~
I. F'UItTH~, CE thst I h~?ve ao iatcntion to retara to m tormer domic~e. and i fateAd to remain in
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Florids. permsnenti;.
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8won~ to and subscribed befors me thts `F~ day of ~
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~ A.D.19 77 _ ~ ' _
R R C ERK OF' C IRCUI T COU2T
ST. LUG 1 E COUNTY, f LOd21 dA • -
BY: ~ ~ ~ -
EPUtY tERK ' ~ -
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