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1'0 Tllh; (:I.F:1tK OF Tlil: t:IRCUIT (~Ol11tT~
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This i~ my declaration ot nomicilc and Citizenship in tt~e Stato of Florida lhel 1 sm tilin~ LAis day in accordancc. and in
conturmily with Scctiun 222.17. FloridA Slatutos. ~
1 wav tormcrl a I~gal resident oi 1~~ ~~1 ~ dnd I
- ~~•~r~ tSt~tel.
n ~C- ~ n 1(~ ~-t , liowcvor. I hsvc changcd my domicile lo .
resided rt -x
' (Stnet and NumAer) •
and am and have ber.n n bo~a Cde residenl at lhe State et Floride since R~ _ dav of `
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o -t'`n -~-~r. c y
~ lc(~M ~ d ~ ~ ~ E_T~
_7 t' ~ .19~, nad I nside At -
- • (Street and I~umbcrl
~t,~~ ~ ~ _ ' ST . l_UG 1 E County. Florida,
lpt~l
and lhi~ slntcment is to be takea as my cleclarution of cit'~e»ship. actual Icga) residcnce aod domicile in the State ot Florida.
IF FOR TNE PURPOSE OF ENROILING IF FOR NOMES?CAD PUkPOSES~
CNILOREN IN SCHOOL~ PIEASE STaIE PLEASE CHECK2 ~
YIIE IR NAMES;
s~I C. c~• t.~7D RECOROEO~ , ;
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. .4;~99'71
. ~79 sc;~~ 8 AM I i: 16
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j I T'[1YTIIF1i Cf:RTIFI' tL•at I wifl r~•nistcr al my l.xal . ddress whrn t1;e r~gistration boal:s mopen. and comps} with xl!
~ othcr rcquimments oi a le~al residcnt of this State. _
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~ 1 FU!tTliF..t CF:It7'IFY thz~. I hati•r no int~•nti~~n to rMurn to m•r fo:m,•; ~inr.,:~i+r, and I intcnd to rcmain ~n
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