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Deciaration of Domicile and Citiz n h' y-
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TO THE CLERK OF THE CIItCUIT COURT,
ST . L UG I E apv~.y, ~,p~p~:
This ia mr aeelar.cion ot nomie0e aaa cttirenshIp in tbe sate ot Flar;a. that t.m tilina te;. a.~ in acoordance. .na in
coaformity wIth Seetion 2?Z.17. F7orida 3tatates. ~
I ~ras fo~ a legal reaideat of ~1~ Cx~a ~T~o?e,~ t~~ ~ot~.k aad I
l(St~1 ( 1
it ~-'S Q-- `1~-- However. I have dunged mp domic~7e to
(&eMt aed Namb~e)
and am and have been a boaa fide resident of tbe State of Fbrida sinoe i~Rw0.r~ \h ~ a{
19~~ and I reside at _~q? Cc ~~t~~~-~ ,
~t
ow~ L' - , ST. LUG I E~~N~~
~•c-•.~ - Count~. Florida.
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and this statemeat is to be taken as m~ declaration of citi:enship. utual kgal residence aad domxi'k in the State ot Florida.
IF fOR THE PURPOSE OF ENROLIING Ii FOR HOMESTEAD PURPOSES~
CHIIOREN IN SCHOOL~ PLEASE STATE PLEASE CHEGKS ~
THEIR NAM~St
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' I FIJRTHER CERTIFY thst I~71 register at my lo¢al address when the registration book,s reopen, and eompl~ with all
g other requirements oi a legal resident of this State. -
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~ I FURTHER CERTIFY t}~t I have no intcntion to ntwn to m former domicik. and I intead to nmain in
` U C E County~
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Sworu to and snb~en'bed before me this ~`3 day of _~~o Q. ~c.i_ `
A 2 ~ i-1 . A.D.19_ ~ 1 . . ;
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~ ROGER P01 TRAS, CLERK OF C IRCUI T COl~2T
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~ ST. LUG I E GOUNTY, FLOR tOA . '%Y~ ~'J ~
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~ _ EPUTY LERK ~ ~ • .
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Ar0 Form ?1 22
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